U.S. patent application number 16/773641 was filed with the patent office on 2020-07-16 for stable, highly pure l-cysteine compositions for injection and methods of use.
The applicant listed for this patent is Exela Pharma Sciences, LLC. Invention is credited to Aruna Koganti, Phanesh Koneru, John Maloney.
Application Number | 20200222448 16/773641 |
Document ID | / |
Family ID | 68536037 |
Filed Date | 2020-07-16 |
United States Patent
Application |
20200222448 |
Kind Code |
A1 |
Maloney; John ; et
al. |
July 16, 2020 |
STABLE, HIGHLY PURE L-CYSTEINE COMPOSITIONS FOR INJECTION AND
METHODS OF USE
Abstract
The subject matter described herein is directed to stable
L-cysteine compositions for injection, comprising: L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof in
an amount from about 10 mg/mL to about 100 mg/mL; Aluminum in an
amount from about 1.0 parts per billion (ppb) to about 250 ppb;
cystine in an amount from about 0.01 wt % to about 2 wt % relative
to L-cysteine; pyruvic acid in an amount from about 0.01 wt % to
about 2 wt % relative to L-cysteine; a pharmaceutically acceptable
carrier, comprising water; headspace 02 that is less than 1.0%;
dissolved oxygen present in the carrier in an amount from about
0.01 parts per million (ppm) to about 1 ppm, wherein the
composition is enclosed in a single-use container having a volume
of from 10 mL to 100 mL. Also described are compositions for a
total parenteral nutrition regimen and methods for their use.
Inventors: |
Maloney; John; (Salisbury,
NC) ; Koganti; Aruna; (Lenoir, NC) ; Koneru;
Phanesh; (Waxhaw, NC) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Exela Pharma Sciences, LLC |
Lenoir |
NC |
US |
|
|
Family ID: |
68536037 |
Appl. No.: |
16/773641 |
Filed: |
January 27, 2020 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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16746028 |
Jan 17, 2020 |
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16773641 |
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16665702 |
Oct 28, 2019 |
10583155 |
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16746028 |
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16248460 |
Jan 15, 2019 |
10478453 |
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16665702 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A23V 2002/00 20130101;
A61K 9/0029 20130101; A61K 33/36 20130101; A61K 31/095 20130101;
A23L 33/17 20160801; A61K 31/4172 20130101; A61K 31/19 20130101;
A61K 33/06 20130101; A61K 33/241 20190101; A61K 31/401 20130101;
A61K 31/191 20130101; A61K 47/02 20130101; A61P 3/02 20180101; A23L
33/175 20160801; A61J 1/1412 20130101; A61K 31/198 20130101; A61K
31/405 20130101; A61K 33/00 20130101; A61K 33/28 20130101; A23L
33/16 20160801; A61K 47/12 20130101; A23V 2002/00 20130101; A23V
2250/052 20130101; A23V 2250/0616 20130101; A23V 2250/1564
20130101; A61K 31/198 20130101; A61K 2300/00 20130101; A61K 33/06
20130101; A61K 2300/00 20130101; A61K 31/19 20130101; A61K 2300/00
20130101 |
International
Class: |
A61K 33/06 20060101
A61K033/06; A61K 31/405 20060101 A61K031/405; A61K 33/36 20060101
A61K033/36; A61K 31/401 20060101 A61K031/401; A61K 9/00 20060101
A61K009/00; A61K 33/00 20060101 A61K033/00; A61K 47/02 20060101
A61K047/02; A61K 33/241 20060101 A61K033/241; A23L 33/16 20060101
A23L033/16; A61K 31/198 20060101 A61K031/198; A61K 31/095 20060101
A61K031/095; A23L 33/175 20060101 A23L033/175; A61K 31/4172
20060101 A61K031/4172; A61K 33/28 20060101 A61K033/28; A61K 31/191
20060101 A61K031/191 |
Claims
1. A solution of L-cysteine comprising, a pharmaceutically
acceptable carrier, about 50 mg/mL of L-cysteine hydrochloride
monohydrate, or equivalent amount of a pharmaceutically acceptable
L-cysteine or a salt or hydrate thereof, a pharmaceutically
acceptable amount of cystine for at least about 12 months from the
time of manufacture of the solution, less than about 150 ppb of
aluminum for at least about 12 months from the time of manufacture
of the solution, a pH from about 1.0 to about 2.5, and wherein the
solution is enclosed in a single-use vial.
2. The solution of claim 1, further comprising less than about 20
ppb fluoride.
3. The solution of claim 1, further comprising less than about 80
ppb iodide.
4. The solution of claim 3, further comprising less than about 20
ppb fluoride.
5. The solution of claim 4, wherein the pharmaceutically acceptable
carrier is aqueous.
6. The solution of claim 5, wherein the container is a coated
vial.
7. The solution of claim 6, wherein the vial is a silica-coated
vial.
8. The solution of claim 1, further comprising lead in an amount
from about 1 ppb to about 10 ppb.
9. The solution of claim 1, further comprising mercury in an amount
from about 0.2 ppb to about 5.0 ppb.
10. The solution of claim 9, further comprising lead in an amount
from about 1 ppb to about 10 ppb.
11. The solution of claim 10, wherein the pharmaceutically
acceptable carrier is aqueous.
12. The solution of claim 11, wherein the vial is a coated
vial.
13. The solution of claim 12, wherein the vial is a silica-coated
vial.
14. The solution of claim 5, further comprising lead in an amount
from about 1 ppb to about 10 ppb and mercury in an amount from
about 0.2 ppb to about 5.0 ppb.
15. The solution of claim 1, wherein the solution is exposed to
inert gas before enclosure in the single-use vial.
16. The solution of claim 1, wherein the vial has a headspace, and
wherein the headspace comprises inert gas.
17. The solution of claim 1, wherein the solution is essentially
free of cystine precipitates.
18. A method of preparing an L-cysteine solution comprising,
preparing a mixture of a pharmaceutically acceptable carrier
comprising less than about 1 ppm dissolved oxygen and L-cysteine or
a pharmaceutically acceptable salt thereof and/or hydrate thereof;
adjusting the pH of said mixture to from about 1.0 to about 2.5;
transferring an amount of the pH-adjusted mixture into a single-use
container; reducing the headspace oxygen in the container; and
sealing the container.
19. The method of claim 18, wherein the headspace oxygen is reduced
by inert gas overlay.
20. The method of claim 18, wherein the headspace oxygen is reduced
by vacuum operation.
21. The method of claim 18, wherein the headspace oxygen is reduced
by a combination of inert gas overlay and vacuum operation.
22. The method of claim 18, wherein the headspace oxygen is reduced
to about 0.5% to about 5.0% v/v.
23. The method of claim 18, wherein the container is a coated
vial.
24. The method of claim 23, wherein the container is a
silica-coated vial.
25. The method of claim 18, wherein at least a portion of the
process is carried out at less than about 60.degree. C.
26. The method of claim 18, wherein at least a portion of the
process is carried out at less than about 30.degree. C.
27. The method of claim 18, wherein the process is carried out
under sterile conditions.
Description
CROSS-REFERENCE TO RELATED APPLICATION(S)
[0001] This application is a continuation of U.S. application Ser.
No. 16/248,460, filed Jan. 15, 2019, which is incorporated herein
in its entirety by reference.
TECHNICAL FIELD
[0002] The subject matter described herein relates generally to
compositions for parenteral administration comprising L-cysteine
that are stable and have desirable safety attributes for extended
periods of time.
BACKGROUND
[0003] L-cysteine is a sulfur-containing amino acid that can be
synthesized de novo from methionine and serine in adult humans.
L-cysteine performs a variety of metabolic functions. For example,
L-cysteine is involved in growth and protein synthesis and it is a
precursor for glutathione, an important intracellular
antioxidant.
[0004] L-cysteine is generally classified as a non-essential amino
acid or "semi-essential" amino acid because it can be synthesized
in small amounts by the human body. However, some adults can still
benefit from L-cysteine supplementation. Further, L-cysteine has
been classified as conditionally essential in some cases. For
example, L-cysteine can be conditionally essential in preterm
infants due to biochemical immaturity of the enzyme cystathionase
that is involved in L-cysteine synthesis. Thus, there are a number
of circumstances in which L-cysteine supplementation can be
desirable.
[0005] The subject matter described herein addresses the
shortcomings of the art by providing L-cysteine compositions that
facilitate the desired supplementation but with an exceptional
safety, purity and stability profile.
BRIEF SUMMARY
[0006] In certain aspects, the subject matter described herein is
directed to a safe, stable L-cysteine composition for parenteral
administration, comprising:
[0007] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof in an amount from about 10 mg/mL to about
100 mg/mL;
[0008] Aluminum (Al) in an amount from about 1.0 part per billion
(ppb) to about 250 ppb;
[0009] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine;
[0010] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0011] a pharmaceutically acceptable carrier, comprising water;
[0012] headspace O.sub.2 that is from about 0.5% to 4.0% from the
time of manufacture to about 1 month from manufacture when stored
at room temperature;
[0013] dissolved oxygen present in the carrier in an amount from
about 0.1 parts per million (ppm) to about 5 ppm from the time of
manufacture to about 1 month from manufacture when stored at room
temperature,
[0014] wherein the composition is enclosed in a single-use
container having a volume of from about 10 mL to about 100 mL.
[0015] In certain aspects, the subject matter described herein is
directed to a safe, stable L-cysteine composition for parenteral
administration, comprising:
[0016] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof in an amount from about 10 mg/mL to about
100 mg/mL;
[0017] Aluminum (Al) in an amount from about 1.0 parts per billion
(ppb) to about 250 ppb;
[0018] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine;
[0019] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0020] a pharmaceutically acceptable carrier, comprising water;
[0021] headspace O.sub.2 that is from about 0.5% to 4.0% from the
time of manufacture to about 1 month from manufacture when stored
at room temperature;
[0022] dissolved oxygen present in the carrier in an amount from
about 0.1 parts per million (ppm) to about 5 ppm from the time of
manufacture to about 1 month from manufacture when stored at room
temperature,
[0023] optionally one or more metals selected from the group
consisting of Lead from about 1.0 ppb to about 10 ppb, Nickel from
about 5 ppb to about 40 ppb, Arsenic from about 0.1 ppb to 10 ppb,
and Mercury from about 0.2 ppb to about 5.0 ppb;
[0024] wherein the composition is enclosed in a single-use
container having a volume of from about 10 mL to about 100 mL.
[0025] In certain aspects, the subject matter described herein is
directed to a safe, stable composition from about 100 mL to about
1000 mL for administration via a parenteral infusion within about
24 to about 48 hours of admixture, comprising a mixture of a
composition of L-Cysteine described herein; and an amino acid
composition that is essentially free of L-Cysteine comprising one
or more amino acids selected from the group consisting of: leucine,
isoleucine, lysine, valine, phenylalanine, histidine, threonine,
methionine, tryptophan, alanine, arginine, glycine, proline,
serine, and tyrosine.
[0026] In certain aspects, the subject matter described herein is
directed to a method of reducing Aluminum administration from a
total parenteral nutrition regimen comprising L-cysteine, the
method comprising, mixing a composition comprising L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof
comprising:
[0027] Aluminum in an amount from about 1.0 parts per billion (ppb)
to about 250 ppb;
[0028] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine; and
[0029] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0030] with a composition comprising one or more amino acids
selected from the group consisting of: leucine, isoleucine, lysine,
valine, phenylalanine, histidine, threonine, methionine,
tryptophan, alanine, arginine, glycine, proline, serine, and
tyrosine; and
[0031] a pharmaceutically acceptable carrier, comprising water,
to form a composition for infusion having a volume of about 100 mL
to about 1000 mL, wherein the Aluminum provided in said parenteral
nutrition regimen is from about 1-2 to about 4-5
micrograms/kg/day.
[0032] In certain aspects, the subject matter described herein is
directed to methods of treating a subject having an adverse health
condition that is responsive to L-cysteine administration,
comprising:
[0033] diluting a stable L-cysteine composition as described herein
with an intravenous fluid to prepare a diluted L-cysteine
composition for infusion; and
[0034] infusing the diluted L-cysteine composition for infusion to
a subject to provide a therapeutically effective dose of L-cysteine
or a pharmaceutically acceptable salt thereof and/or hydrate
thereof to the subject in a therapeutically effective dosing
regimen.
[0035] In certain aspects, the subject matter described herein are
directed to methods of administering L-Cysteine together with a
composition for parenteral nutrition, comprising:
[0036] diluting a stable L-cysteine composition for injection as
described herein with a parenteral nutrition composition to form a
mixture; and
[0037] parenterally administering the mixture to a subject in need
thereof in a therapeutically and/or nutritionally effective dose.
In one aspect, the subject is a preterm infant or newborn to about
1 month of age. Some of these subjects may weigh from about 0.5
kilos to about 2.0 kilos. In another aspect, the subject is a
pediatric patient that is of about 1 month to six months of age.
Some of these subjects may weigh from about 0.2 kilos to about 20
kilos. In another aspect, the subject is an adult requiring
parenteral nutrition.
[0038] These and other aspects are more fully described herein.
BRIEF DESCRIPTION OF THE FIGURES
[0039] FIG. 1 depicts the overall trend of the results from the
experiments that demonstrate the effectiveness of the Head Space
Reduction (HSR) cycle in attaining reduced and consistent dissolved
oxygen (DO) levels in the finished drug product. The results showed
a trend with an increase in dissolved oxygen level from 0.36 parts
per million (ppm) recorded during compounding, to an average of
5.12 ppm measured after filling, a further increase to an average
of 9.92 ppm while loading the Lyophilizer, and finally a reduction
of dissolved oxygen to an average of 0.50 ppm after headspace
reduction. This demonstrates the specific phase of manufacturing at
which and to the specific level that oxygen needs to be controlled
in the product.
[0040] FIG. 2 depicts the overall trend of the results from the
experiments that demonstrate the effectiveness of the Head Space
Reduction (HSR) cycle in attaining reduced and consistent dissolved
oxygen (DO) levels in the finished drug product. The results showed
a trend with an increase in dissolved oxygen level from 0.36 parts
per million (ppm) recorded during compounding, to an average of
5.12 ppm measured after filling, a further increase to an average
of 9.92 ppm while loading the Lyophilizer, and finally a reduction
of dissolved oxygen to an average of 0.50 ppm after headspace
reduction.
[0041] FIG. 3 depicts a process filler set up to fill and reduce
head space oxygen.
[0042] FIG. 4 shows data for the process of Example 4. The plot
shows comparison of oxygen headspace control between the
lyophilizer chamber headspace control method versus the high-speed
filler vacuum stoppering system. The time zero oxygen headspace
results for the batch PROT-000213 are shown in comparison to the
previously manufactured lots. Results shown were measured at the
time of manufacturing on samples of vials from the batches.
[0043] FIG. 5 depicts the data measured for dissolved oxygen levels
in the process of Example 4.
DETAILED DESCRIPTION
[0044] The presently disclosed subject matter will now be described
more fully hereinafter. However, many modifications and other
embodiments of the presently disclosed subject matter set forth
herein will come to mind to one skilled in the art to which the
presently disclosed subject matter pertains having the benefit of
the teachings presented in the foregoing descriptions. Therefore,
it is to be understood that the presently disclosed subject matter
is not to be limited to the specific embodiments disclosed and that
modifications and other embodiments are intended to be included
within the scope of the appended claims. In other words, the
subject matter described herein covers all alternatives,
modifications, and equivalents that are within the ordinary skill
in the art. In the event that one or more of the incorporated
literature, patents, and similar materials differs from or
contradicts this application, including but not limited to defined
terms, term usage, described techniques, or the like, this
application controls. Unless otherwise defined, all technical and
scientific terms used herein are intended to have the same meaning
as commonly understood by one of ordinary skill in this field. All
publications, patent applications, patents, and other references
mentioned herein are incorporated by reference in their
entirety.
[0045] Advantageously, it has been found that the desirable
attributes of L-cysteine compositions for infusion can be obtained
without the characteristic impurity profile that is known in the
art. Such impurity profile makes the product less safe to be used
by patients, in particular, preterm and term infants and pediatric
patients of 1 month to 1 year as well as critically ill adults.
Specifically, the art formulations fail to address the issues
related to the amounts of Aluminum and cystine, among other
impurities, that can be routinely present and co-administered with
L-cysteine. It has now been found that L-cysteine compositions for
injection can be prepared using the methods described herein
whereby the compositions unexpectedly comprise exceedingly low
levels of Aluminum and other undesirable impurities, such as
cystine, pyruvic acid, certain heavy metals and certain ions. As a
result, the present compositions and methods of using said
compositions are safer to the intended subject compared to the
currently available compositions and methods. Further, the product
is also rendered more stable by virtue of lower levels of cystine
generated by the manufacturing processes described herein.
[0046] As described herein, without being bound to theory, it has
been found that the problems of safety, purity and stability are
results not simply or directly from the level of Aluminum, but are
also intertwined with dissolved oxygen levels in the composition
and oxygen in the headspace as well as certain heavy metals and
certain ions that may leach or be extracted out of the container
closure.
[0047] An L-Cysteine for injection product was prepared with the
aim to provide a product that would be acceptable for
administration to infants, pediatric and adult patients. High
quality Schott glass vials and stoppers were used. See Example 2.
It was however found that glass containers contribute more
significantly than expected to the Aluminum content of L-cysteine
compositions stored therein to the point where the product did not
meet the specifications for certain components. Products having
such Aluminum levels would likely be deemed unsafe by the FDA. As
such, efforts were focused on identifying the sources of Aluminum
in the product and attempts to minimize it in the product. These
efforts led to the unexpected discovery that simply removing a
source of Aluminum by replacing glass with plastic did not result
in a product having the desired properties.
[0048] Additional efforts to identify the root cause for the
product failure led to the finding that the product likely failed
because oxygen entered the plastic container and into the product
at a rate higher than previously expected or predicted. For
example, the plastic container product failed in some cases in less
than 1-2 months. See Example 3. This finding was also unexpected.
Increased oxygen levels in the product led to unacceptable levels
of oxidation products, such as cystine, which precipitated and
caused particulates in the product. Particulates are dangerous in
injectable compositions and create a safety concern, in addition to
the stability issue to the product.
[0049] However, the precipitation may have been exacerbated by
reduction in Aluminum since Aluminum in solution may have a
stabilizing effect. Consequently, removing Aluminum may have the
unintended consequence of increased precipitation and product
failure in the presence of even small amounts of oxygen in the
container. This was unexpected.
[0050] Additionally, controlling heat in the process including
during the compounding and/or sterilization activities,
unexpectedly was found to be beneficial for preparing stable
L-Cysteine compositions described herein. This was surprising
because L-Cysteine has been used in parenteral products as an
excipient where the product is subjected to terminal sterilization
which exposes the product to high temperatures such as 120.degree.
C.
[0051] Some subjects that would be receiving L-Cysteine
supplementation are, as discussed elsewhere herein, pre-term
neonates or full-term infants that are underweight, or infants that
may be full term and are not underweight but are still candidates
for treatment, in many cases for longer term treatment. For
example, some of these subjects may be treated with L-Cysteine for
several days or several weeks, even several months. In these cases,
it is imperative that the subjects are not exposed to potentially
toxic or undesirable levels of some anions and heavy metals that
may be present in drug products. Examples of such heavy metals
include but not limited to Lead, Nickel, Arsenic and Mercury.
Examples of anions that should be monitored include but not limited
to iodide, and fluoride. Many of these are introduced into drug
products through manufacturing processes, container closure
systems, or the drug substance and the excipients. The levels of
the heavy metals and anions may not be a concern with many drug
products because the patient population exposed to the drug may be
not as vulnerable as in the case of L-Cysteine, or the dosing of
such drug products may be very limited, i.e., for one or a few
doses. For the reasons noted above, it is imperative that
L-Cysteine drug product, its administration, its manufacture, and
its container closure system are carefully evaluated for the levels
of heavy metals and selected anions. The state of the art is
lacking in providing any specific guidance on the need for this
evaluation, the specific heavy metals and anions on which to focus,
and how to achieve control over the levels. The L-Cysteine
compositions, methods of administration and manufacture, selection
of container closure system and the excipients and the drug
substance as described herein fill that need.
[0052] Thus, in summary, as described herein, reducing aluminum
drastically to extremely low levels in the product, reducing oxygen
to very low levels in the process and in the composition, and/or
reducing or eliminating heat in the process, and in consideration
of data showing selection of the appropriate container, stopper,
drug substance, and excipients, individually or in combination(s),
resulted in achieving a safe, stable composition of L-Cysteine
injection that could be administered safely even to very delicate
pediatric subjects such as pre-term neonatal subjects that are as
young as a day and may weigh as low as 0.5 kilos, for a few days to
several weeks.
[0053] L-cysteine for injection is a marketed product used as a
component of a nutritional supplement regimen referred to as total
parenteral nutrition (TPN). The Aluminum content in known
L-cysteine compositions for injection is higher than desired.
Moreover, when the L-cysteine composition is combined with certain
amino acids prior to administration, the amino acids contribute
some amount of Aluminum, and Aluminum levels can further increase.
TPN admixtures constitute several other components (in addition to
amino acid mixtures) such as electrolytes (such as Potassium
Phosphate, Calcium gluconate, and sodium acetate). These
electrolytes may also contribute to high Aluminum levels in TPN
admixtures (Smith et al., Am. J. Health Syst. Pharm., vol. 64, Apr.
1, 2007, pp. 730-739). This is of particular concern since
administration of the L-cysteine is often to infants (some of them
pre-term) for nutritional support. A focus of the subject matter
described herein is in minimizing the Aluminum levels coming from
L-Cysteine compositions so that when admixed with other ingredients
of TPN admixtures, the overall Aluminum levels could be reduced
while minimizing introduction of undesirable materials such as
heavy metals, anions, and particulates. All of these components are
present in amounts that are below levels determined to be safe.
[0054] L-cysteine (2-Amino-3-sulfhydrylpropanoic acid) is a
sulfur-containing amino acid having a structure according to
Formula I:
##STR00001##
L-cysteine performs a variety of metabolic functions. For example,
L-cysteine is a precursor for antioxidants, such as glutathione and
taurine, that support oxidative defense and a healthy immune
system. L-cysteine can also play a role in the synthesis of
essential fatty acids and facilitate production of cell membranes
and protective covers of nerve endings. Additionally, L-cysteine
can be an important precursor for many proteins, such as structural
proteins in connective tissue. Thus, the depletion or absence of
cystathionase activity in premature fetuses and newborns to
synthesize L-cysteine de novo has led to the categorization of
L-cysteine as a conditionally essential amino acid. Additionally,
administration of L-cysteine can be valuable to treat a number of
conditions in subjects, whether or not the subject is a premature
infant or neonate.
[0055] Known pharmaceutical compositions that contain L-cysteine
can typically contain undesirable levels of certain components.
Cystine is an oxidation product of L-cysteine. Like L-cysteine,
cystine can be synthesized in the liver. Further, both L-cysteine
and cystine can be present as amino acid residues in proteins.
However, because cystine is an oxidation product of L-cysteine, it
is possible that the amount of cystine can increase over time.
Thus, it may be desirable to maintain the amount of cystine within
predetermined levels over time. For all practical purposes, cystine
and L-Cystine are used interchangeably herein. Pyruvic acid is
another undesirable compound that can be found in L-cysteine
compositions known in the art. It is possible that the amount of
pyruvic acid in these compositions can increase over time. Thus, it
may be desirable to maintain the amount of pyruvic acid within
predetermined levels over time.
[0056] Perhaps of most concern is the level of Aluminum in known
L-cysteine compositions. Aluminum contamination and associated
Aluminum toxicity can lead to a number of adverse conditions such
as metabolic bone disease, neurodevelopmental delay, cholestasis,
osteoporosis, growth failure, dementia, and the like. It is
desirable to allow no more than 4-5 mcg/kg/day of Aluminum to avoid
toxicity. It is preferable to keep the dose on the conservative
side as much as possible, i.e., at 4 mcg/kg/day to avoid accidental
overdosing in case Aluminum from some other reason (unanticipated
or unknown source or due to human error) is introduced. Up to now,
known L-cysteine compositions contain up to 5000 ppb Aluminum. Even
levels of 900 ppb are known in currently available products. In
stark contrast, described herein are compositions that provide a
therapeutically effective amount of L-cysteine, while containing
less than 250 ppb Aluminum, including, in certain embodiments, less
than 200 ppb, or less than 175 ppb, or less than 150 ppb, or less
than 125 ppb, or less than 120 ppb, or less than 100 ppb, or less
than 80 ppb, or less than 75 ppb, or less than 60 ppb, or less than
50 ppb, or less than 40 ppb, or less than 30 ppb, or less than 20
ppb, or less than 10 ppb, or less than 5 ppb, or less than 1.0 ppb.
Thus, what has now been achieved is an unexpected and substantial
reduction in Aluminum content of an L-Cysteine composition that
permits exposure to less than or equal to 4-5 micrograms per
kilogram per day (.mu.g/kg/d) to avoid or minimize Aluminum
toxicity while still providing therapeutically effective L-cysteine
in a stable composition. In some aspects, the compositions
described herein permit an Aluminum dose of as low as 0.6
micrograms/kg/d, improving significantly the safety of the
L-Cysteine product and its administration.
[0057] High risk patient populations for Aluminum toxicity in the
context of parenteral nutrition include the following: Renal
Insufficiency and Infants: Renal elimination is a major source of
Aluminum removal. Therefore, patients with renal compromise and
infants with immature renal function are at risk of Aluminum
accumulation. Pregnant women: The fetus is vulnerable to Aluminum
contamination in parenteral nutrition since Aluminum may be
transferred across the placenta. Elderly: Age is a well-known risk
factor for renal impairment and thus results in a higher risk of
Aluminum toxicity. Other studies suggest that Aluminum toxicity may
be due to increased absorption of Aluminum due to a weakened GI
protective barrier.
[0058] The compositions and methods described herein provide the
means to support the nutritional needs of patients, including
preterm infants or infants with low birth weight, but reduce the
risks associated with Aluminum ingestion. Most preterm and low
birth weight infants tend to require parenteral nutrition with
amino acid supplementation during their hospital stay. However, as
mentioned above, infants are a particularly high-risk population
for Aluminum toxicity. To address such issues, in certain
embodiments, the compositions comprise about 34.5 mg/mL of
L-cysteine (measured as a base, i.e., not measured as HCl and
monohydrate) and no more than 250 ppb, preferably about 120 ppb, or
lower, of Aluminum. These compositions with no more than 120 ppb of
Aluminum, and in certain embodiments, about 120 ppb, or 100 ppb, or
80 ppb, or 60 ppb, or 50 ppb, or 20 ppb, or 10 ppb or 5 ppb or 1.0
ppb, or any suitable subrange encompassing the specific values, in
units of 5 ppb, permit great flexibility with respect to the amino
acid supplementation for TPN preparations.
[0059] L-Cysteine injection is administered after being added to a
parenteral nutrition composition such as an amino acid composition,
or a sugar-source such as dextrose or a lipid source or a
combination of the foregoing. It is preferred that L-Cysteine is
added to the amino acid composition, which may be administered
separately or in combination with other components of a parenteral
nutrition regime such as sugars and lipids. For present purposes,
the Aluminum content of the combined L-Cysteine and amino acid
solution is of interest, and is monitored. L-Cysteine may be dosed
at 15 mg per gram of amino acids or sometimes at a high
concentration, i.e., 40 mg/gram of amino acids.
[0060] Commercially available amino acid product labeling for
example indicates that 25 mcg/L of Aluminum is contributed from the
product itself. The general recommended maximum dose is 4 g of
amino acids/kg body weight. Generally amino acids solutions are
available as 10% (10 g/100 mL) which would necessitate 40 mL volume
to be administered for a 1 kg preterm neonatal patient. Based on
this the amino acids solution is expected to contribute to about 1
mcg/kg/day. This leaves about 3 mcg/kg/day from other sources
including L-cysteine. In some scenarios, there may be five or more
other components including L-cysteine that can contribute to
varying levels of Aluminum in TPN mixtures. For the sake of
illustration, assume there are five contributors that contribute
equally. The expected maximum Aluminum contribution that may come
from L-Cysteine would be (3 mcg/kg/day)/5=0.6 mcg/kg/day. In light
of Smith et al. (Am. J. Health Syst. Pharm., vol. 64, Apr. 1, 2007,
pp. 730-739), significant contributors to Aluminum levels besides
amino acids and L-Cysteine are Potassium Phosphate, Potassium
Acetate, Sodium Acetate, and Calcium Gluconate. The reference
indicates that contributions from all of these are high such that
100% of pediatric (including preterm and full-term infants) TPNs
have >4 .mu.g/kg/day (range 12-162 .mu.g/kg/day) of Aluminum
coming from various sources. Even after carefully selecting the
products with the least Aluminum content components among those
available for treatment, the TPNs have >4 .mu.g/kg/day. This
finding for example highlights the need to systematically reduce
the amount of Aluminum in each product that will be incorporated
into a TPN admixture. The current efforts are directed to providing
L-Cysteine compositions that offer exceedingly low Aluminum
levels.
[0061] One of the difficulties with establishing dosing levels of
L-Cysteine with an eye to keep the Aluminum administration to below
or at a certain amount is the lack of uniformity in the art as to
how to categorize the subjects in terms of their age and weight.
This imprecise terminology has been used often blurring the
boundaries among the patient groups, making it difficult to assess
which patient should receive what amount of L-Cysteine, and hence
how much Aluminum would result. As such, the art does not suggest
what the levels of Aluminum exposure should be, nor does it provide
a solution that minimizes Aluminum exposure during a TPN regimen.
Following Table 1 shows a streamlined approach to categorize the
potential patient population and their proposed daily doses of
L-Cysteine.
TABLE-US-00001 TABLE 1 Daily Dosage of L-Cysteine Protein.sup.a
Requirement L-Cysteine Dosage L-Cysteine Dosage Age
(g/kg/day).sup.1 (mg cysteine/g AA) (mg cysteine/kg/day) Preterm
and term infants less than 1 month 3 to 4 15 45 to 60 of age
Pediatric patients 1 month to less than 1 2 to 3 15 30 to 45 year
of age Pediatric patients 1 year to 11 years of age 1 to 2 15 15 to
30 Pediatric patients 12 years to 17 years of 0.8 to 1.5 5 .sup. 4
to 7.5 age Adults: Stable Patients 0.8 to 1.sup. 5 4 to 5 Adults:
Critically Ill Patients 1.5 to 2.sup. 5 7.5 to 10 .sup.aProtein is
provided as amino acids. When infused intravenously, amino acids
are metabolized and utilized as the building blocks of protein.
[0062] From the above Table, it should be noted that the most need
for L-Cysteine is for the preterm infant. Therefore, to safely
administer L-Cysteine compositions, the Aluminum level in the
compositions must be substantially less than what is in
commercially available products and those described in the art.
There has been no specific guidance in the art however of how low
this Aluminum level should be, and how to achieve compositions with
such low Aluminum levels. To the extent there may be some guidance,
the levels proposed are considered higher than desirable.
[0063] L-Cysteine Injection as presented herein in some embodiments
contains no more than 120 mcg/L (120 ppb) of aluminum (0.0035 mcg
of aluminum/mg of cysteine). The maximum dosage of aluminum from
L-Cysteine Injection is not more than 0.21 mcg/kg/day when preterm
and term infants less than 1 month of age are administered the
dosage of L-Cysteine injection (15 mg cysteine/g of amino acids and
4 g of amino acids/kg/day). If L-Cysteine is added to TPN
containing amino acid and dextrose solutions (which each may
contain up to 25 mcg/L of aluminum) as well as other additive drug
products, the total amount of aluminum administered to the patient
from the final admixture should be considered and maintained at no
more than 5 mcg/kg/day.
[0064] However, with prolonged parenteral administration in
patients with renal impairment, the aluminum contained in
L-Cysteine Injections disclosed herein may reach toxic levels.
Preterm infants are at a greater risk for aluminum toxicity because
their kidneys are immature, and they require large amounts of
calcium and phosphate solutions, which also contain aluminum.
Prolonged administration herein may mean at least one week, or may
be up to 2-4 weeks. In some aspects, the administration could
continue for up to 24 weeks.
[0065] Patients with renal impairment, including preterm infants,
who receive parenteral levels of aluminum at greater than 4 to 5
mcg/kg/day, accumulate aluminum at levels associated with central
nervous system and bone toxicity. Tissue loading may occur at even
lower rates of administration. Therefore, it is essential that
aluminum levels in the L-Cysteine drug product are carefully
controlled and kept at as low as possible. Such embodiments are
disclosed herein.
[0066] Looking more specifically at contribution of Aluminum by the
prior products, data show that the Aluminum levels of 5,000 ppb or
even the 900 ppb associated with these products are not desirable
or acceptable. Tables 2-3 report the Aluminum contribution from the
commercial product of prior art with 900 ppb or 5000 ppb Aluminum
level based on two scenarios: a) an L-Cysteine dosing regimen based
on 15 mg/gram of amino acids; and b) an L-Cysteine dosing regimen
based on 40 mg/gram of amino acids. The Tables also show the
Aluminum contribution from an L-Cysteine product as described
herein and having a level of 120 ppb.
TABLE-US-00002 TABLE 2 Aluminum Contribution (Based on a Cysteine
Dose of 15 mg/g of Amino Acids) from an L-Cysteine Product with 900
ppb, 5,000 ppb, or 120 ppb of Aluminum Aluminum Aluminum Aluminum
Contribution Contribution Contribution L-Cysteine Dose at from 900
ppb from 5,000 from 120 ppb (15 mg/g AA) product ppb product
product Age mg/kg/day mL/kg/day mcg/kg/day mcg/kg/day mcg/kg/day
Preterm and 45 to 60 1.31 to 1.74 1.18 to 1.57 6.53 to 8.70 0.157
to 0.209 term infants less than 1 month Pediatric 30 to 45 0.87 to
1.31 0.79 to 1.17 4.35 to 6.52 0.1 to 0.157 patients 1 month to
less than 1 yr Pediatric 15 to 30 0.44 to 0.87 0.40 to 0.79 2.18 to
4.35 0.053 to 0.1 patients 1 yr to 11 yrs Pediatric .sup. 4 to 7.5
0.18 to 0.22 0.11 to 0.20 0.58 to 1.09 0.022 to 0.026 patients 12
yrs to 17 yrs Adults: Stable 4 to 5 0.18 to 0.23 0.11 to 0.14 0.58
to 0.73 0.022 to 0.028 Patients Adults: 7 to 10 0.32 to 0.46 0.2 to
0.28 1.02 to 1.46 0.038 to 0.055 Critically ill patients
TABLE-US-00003 TABLE 3 Aluminum Contribution (Based on a Cysteine
Dose of 40 mg/g of Amino Acids) from an L-Cysteine Product with 900
ppb, 5,000 ppb, or 120 ppb of Aluminum Aluminum Aluminum Aluminum
Contribution Contribution Contribution L-Cysteine Dose at from 900
from 5,000 ppb from 120 ppb (40 mg/g AA) ppb product product
product Age mg/kg/day mL/kg/day mcg/kg/day mcg/kg/day mcg/kg/day
Preterm and 120 to 160 3.48 to 4.64 3.13 to 4.17 17.39 to 23.19
0.42 to 0.56 term infants less than 1 month Pediatric 80 to 120
2.32 to 3.48 2.09 to 3.13 11.59 to 17.39 0.28 to 0.42 patients 1
month to less than 1 yr Pediatric 40 to 80 1.16 to 2.32 1.05 to
2.09 5.79 to 11.59 0.14 to 0.28 patients 1 yr to 11 yrs Pediatric
10.66 to 20 0.31 to 0.58 0.28 to 0.53 1.56 to 2.94 0.04 to 0.07
patients 12 yrs to 17 yrs Adults: Stable 10.66 to 13.33 0.31 to
0.39 0.28 to 0.35 1.56 to 1.94 0.04 to 0.047 Patients Adults: 18.7
to 26.7 0.54 to 0.77 0.49 to 0.70 2.72 to 3.89 0.065 to 0.09
Critically ill patients
[0067] If the preterm infants are given the high dose of L-cysteine
(40 mg/gram of amino acids), this requires that a dose of 160 mg/kg
(4.64 mL/kg) of L-Cysteine at a (base) concentration of 34.5 mg/mL
be delivered. (See Table 3 above). The compositions described
herein contribute about 0.0035 mcg Aluminum per each mg of
L-cysteine, or 0.12 mcg of Aluminum per each mL at 120 ppb. Thus, a
dose of 160 mg/kg (4.64 mL/kg) L-cysteine delivers only 0.56 mcg/kg
Aluminum at 40 mg/g of AA dosing on the higher end, or 0.157 mcg/kg
at 15 mg/g of AA dosing on the lower end. See Tables 2-3. In
contrast, if art products were to be used, these patients would
receive either 23 mcg/kg (for the product that contains 5,000 ppb
of Aluminum), or 4.2 mcg/kg of aluminum (for the product that
contains 900 ppb of Aluminum). Given that the total daily intake
permissible for Aluminum is expected to be ideally less than 4-5
mcg/kg, the art products already exceed the entire daily Aluminum
level and do not leave room for Aluminum contribution from other
TPN components. Therefore, these known high Aluminum-containing
products are likely to be deemed unsafe by the FDA and are neither
desirable nor acceptable. In contrast, the L-Cysteine compositions
presented herein provide Aluminum levels ranging from 10 ppb to
about 250 ppb. Taking 20 ppb, 50 ppb, 120 ppb, and 150 ppb as
illustrations, the Tables below estimate the amount of Aluminum
delivered for each class of patients using 34.5 mg/mL L-Cysteine
product when being dosed at 15 mg/g of Amino Acids.
TABLE-US-00004 TABLE 4 Aluminum Contribution (Based on a Cysteine
Dose of 15 mg/g of Amino Acids) from an L-Cysteine Product (34.5
mg/mL) with 20 ppb, 50 ppb, 120 ppb or 150 ppb of Aluminum Aluminum
Aluminum Aluminum L-Cysteine Contribution Contribution Contribution
Aluminum Dose at from 20 ppb from 50 ppb from 120 ppb Contribution
15 mg/g AA product product product from 150 ppb Age mg/kg/day
mcg/kg/day mcg/kg/day mcg/kg/day mcg/kg/day Preterm 45 to 60 0.026
to 0.035 0.065 to 0.088 0.157 to 0.209 0.195 to 0.26 and term
infants less than 1 month Pediatric 30 to 45 0.017 to 0.026 0.043
to 0.065 0.1 to 0.157 0.13 to 0.195 patients 1 month to less than 1
yr Pediatric 15 to 30 0.009 to 0.017 0.022 to 0.044 0.053 to 0.11
0.066 to 0.125 patients 1 yr to 11 yrs Pediatric .sup. 4 to 7.5
0.004 0.009 to 0.01 0.022 to 0.026 0.027 to 0.033 patients 12 yrs
to 17 yrs Adults: 4 to 5 0.004 0.009 to 0.12 0.022 to 0.028 0.027
to 0.035 Stable Patients Adults: 7 to 10 0.006 to 0.009 0.016 to
0.23 0.038 to 0.055 0.048 to 0.069 Critically ill patients
[0068] In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 45 to 60 mg/kg/day
of L-Cysteine and from about 0.02 to about 0.3 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 30 to 45 mg/kg/day
of L-Cysteine and from about 0.01 to about 0.25 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 15 to 30 mg/kg/day
of L-Cysteine and from about 0.005 to about 0.15 mcg/kg/day of
Aluminum.
[0069] In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 4 to 7.5 mg/kg/day
of L-Cysteine and from about 0.003 to about 0.04 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 4 to 5 mg/kg/day of
L-Cysteine and from about 0.003 to about 0.04 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 7 to 10 mg/kg/day
of L-Cysteine and from about 0.004 to about 0.08 mcg/kg/day of
Aluminum.
[0070] In some embodiments, a method of safe administration of
L-Cysteine comprises administering to preterm and term infants of
less than 1 month of age a parenteral L-Cysteine composition that
delivers 45 to 60 mg/kg/day of L-Cysteine and from about 0.02 to
about 0.3 mcg/kg/day of Aluminum, admixed with a parenteral
nutrition composition. In some embodiments, a method of safe
administration of L-Cysteine comprises administering to pediatric
patients 1 month to less than 1 year of age a parenteral L-Cysteine
composition that delivers 30 to 45 mg/kg/day of L-Cysteine and from
about 0.01 to about 0.25 mcg/kg/day of Aluminum, admixed with a
parenteral nutrition composition. In some embodiments, a method of
safe administration of L-Cysteine comprises administering to
pediatric patients 1 year to 11 years of age a parenteral
L-Cysteine composition that delivers 15 to 30 mg/kg/day of
L-Cysteine and from about 0.005 to about 0.15 mcg/kg/day of
Aluminum, admixed with a parenteral nutrition composition.
[0071] In some embodiments, a method of safe administration of
L-Cysteine comprises administering to pediatric patients 12 years
to 17 years of age a parenteral L-Cysteine composition that
delivers 4 to 7.5 mg/kg/day of L-Cysteine and from about 0.003 to
about 0.04 mcg/kg/day of Aluminum, admixed with a parenteral
nutrition composition. In some embodiments, a method of safe
administration of L-Cysteine comprises administering to adult
stable patients a parenteral L-Cysteine composition that delivers 4
to 5 mg/kg/day of L-Cysteine and from about 0.003 to about 0.04
mcg/kg/day of Aluminum, admixed with a parenteral nutrition
composition. In some embodiments, a method of safe administration
of L-Cysteine comprises administering to critically ill adult
patients a parenteral L-Cysteine composition that delivers 7 to 10
mg/kg/day of L-Cysteine and from about 0.004 to about 0.08
mcg/kg/day of Aluminum, admixed with a parenteral nutrition
composition.
[0072] Further, taking 20 ppb, 50 ppb, 120 ppb, and 150 ppb as
illustrations, the Tables below estimate the amount of Aluminum
delivered for each class of patients using 34.5 mg/mL L-Cysteine
product when being dosed at 40 mg/g of Amino Acids.
TABLE-US-00005 TABLE 5 Aluminum Contribution (Based on a Cysteine
Dose of 40 mg/g of Amino Acids) from an L-Cysteine Product (34.5
mg/mL) with 20 ppb, 50 ppb, 120 ppb or 150 ppb of Aluminum Aluminum
Aluminum Aluminum L-Cysteine Contribution Contribution Contribution
Aluminum Dose at 40 from 20 ppb from 50 ppb from 120 ppb
Contribution mg/g AA product product product from 150 ppb Age
mg/kg/day mcg/kg/day mcg/kg/day mcg/kg/day mcg/kg/day Preterm 120
to 160 0.07 to 0.09 0.175 to 0.233 0.42 to 0.56 0.525 to 0.7 and
term infants less than 1 month Pediatric 80 to 120 0.047 to 0.07
0.117 to 0.175 0.28 to 0.42 0.35 to 0.525 patients 1 month to less
than 1 yr Pediatric 40 to 80 0.023 to 0.047 0.058 to 0.117 0.14 to
0.28 0.175 to 0.35 patients 1 yr to 11 yrs Pediatric 10.66 to 20
0.007 to 0.012 0.017 to 0.029 0.04 to 0.07 0.05 to 0.088 patients
12 yrs to 17 yrs Adults: 10.66 to 13.33 0.007 to 0.008 0.017 to
0.02 0.04 to 0.047 0.05 to 0.059 Stable Patients Adults: 18.7 to
26.7 0.011 to 0.015 0.027 to 0.038 0.065 to 0.09 0.081 to 0.113
Critically ill patients
[0073] In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 120 to 160
mg/kg/day of L-Cysteine and from about 0.05 to about 0.8 mcg/kg/day
of Aluminum. In some embodiments, parenteral L-Cysteine
compositions provide about 35 mg/mL of L-Cysteine to deliver 80 to
120 mg/kg/day of L-Cysteine and from about 0.03 to about 0.6
mcg/kg/day of Aluminum. In some embodiments, parenteral L-Cysteine
compositions provide about 35 mg/mL of L-Cysteine to deliver 40 to
80 mg/kg/day of L-Cysteine and from about 0.01 to about 0.4
mcg/kg/day of Aluminum.
[0074] In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 10 to 20 mg/kg/day
of L-Cysteine and from about 0.005 to about 0.1 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver 10 to 15 mg/kg/day
of L-Cysteine and from about 0.005 to about 0.06 mcg/kg/day of
Aluminum. In some embodiments, parenteral L-Cysteine compositions
provide about 35 mg/mL of L-Cysteine to deliver about 18 to 28
mg/kg/day of L-Cysteine and from about 0.01 to about 0.15
mcg/kg/day of Aluminum.
[0075] In some embodiments, a method of safe administration of
L-Cysteine comprises administering to preterm and term infants of
less than 1 month of age a parenteral L-Cysteine composition that
delivers 120 to 160 mg/kg/day of L-Cysteine and from about 0.05 to
about 0.8 mcg/kg/day of Aluminum, admixed with a parenteral
nutrition composition. In some embodiments, a method of safe
administration of L-Cysteine comprises administering to pediatric
patients 1 month to less than 1 year of age a parenteral L-Cysteine
composition that delivers 80 to 120 mg/kg/day of L-Cysteine and
from about 0.03 to about 0.6 mcg/kg/day of Aluminum, admixed with a
parenteral nutrition composition. In some embodiments, a method of
safe administration of L-Cysteine comprises administering to
pediatric patients 1 year to 11 years of age a parenteral
L-Cysteine composition that delivers 40 to 80 mg/kg/day of
L-Cysteine and from about 0.01 to about 0.4 mcg/kg/day of Aluminum,
admixed with a parenteral nutrition composition.
[0076] In some embodiments, a method of safe administration of
L-Cysteine comprises administering to pediatric patients 12 years
to 17 years of age a parenteral L-Cysteine composition that
delivers 10 to 20 mg/kg/day of L-Cysteine and from about 0.005 to
about 0.1 mcg/kg/day of Aluminum, admixed with a parenteral
nutrition composition. In some embodiments, a method of safe
administration of L-Cysteine comprises administering to adult
stable patients a parenteral L-Cysteine composition that delivers
10 to 15 mg/kg/day of L-Cysteine and from about 0.005 to about 0.06
mcg/kg/day of Aluminum, admixed with a parenteral nutrition
composition. In some embodiments, a method of safe administration
of L-Cysteine comprises administering to critically ill adult
patients a parenteral L-Cysteine composition that delivers 18 to 28
mg/kg/day of L-Cysteine and from about 0.01 to about 0.15
mcg/kg/day of Aluminum, admixed with a parenteral nutrition
composition.
[0077] Accordingly, what is provided herein, among other things,
are therapeutically and/or nutritionally effective amounts of
L-cysteine with significantly minimized risk of Aluminum
toxicity.
I. Definitions
[0078] As used herein, the term "stable" refers to a composition
that has the component profiles described herein, for example,
Aluminum, L-Cystine, and pyruvic acid, at the levels described and
for the amount of time identified. In other words, a stable
composition will contain the specified levels of all components for
sufficient period of time to enable the composition to be
commercially manufactured, stored, shipped, and administered in a
clinical setting. In general, products are considered stable if the
period of time is three months, or three to six months, or three to
12 months, or three to 15 months, or three to 18 months or three to
24 months.
[0079] As used herein, the term "dissolved oxygen" refers to oxygen
that is found in the aqueous carrier of the compositions.
Distinguished from dissolved oxygen is the headspace oxygen. As
used herein, the term "headspace oxygen" refers to the oxygen that
is found in the headspace volume of the sealed container comprising
the composition.
[0080] As used herein, the term "cystine precipitate" refers to
undissolved L-cystine. The undissolved cystine may be visually
detected as particulate matter in solution.
[0081] As used herein, "subject" refers to a mammal that may
benefit from the administration of a composition described herein.
In one aspect, the mammal may be a human.
[0082] The term "prophylaxis" or "prophylactic" refers to the
continued absence of symptoms of the disease or condition that
would be expected had the combination not been administered.
[0083] As used herein, the terms "formulation" and "composition"
are used interchangeably and refer to a mixture of two or more
compounds, elements, or molecules.
[0084] In some aspects, the terms "formulation" and "composition"
may be used to refer to a mixture of one or more active agents with
a carrier or other excipients. Compositions can take nearly any
physical state, including solid and/or liquid (i.e. solution).
Furthermore, the term "dosage form" can include one or more
formulation(s) or composition(s) provided in a form suitable for
administration to a subject. As used herein, the term "compositions
for injection" and the like, refers to a composition that is
intended for injection, including dilution and admixing with other
components prior to injection. Said injection may be administered
as an intravenous injection, or as an intravenous infusion. When
administered as infusions, the compositions may be administered
through a peripheral vein in limited circumstances or more commonly
through a central vein. One of skill in the art would have
experience with such administrations.
[0085] As used herein, "effective amount" refers to an amount of an
ingredient, such as L-cysteine, which, when included in a
composition, is sufficient to achieve an intended compositional or
physiological effect. Thus, a "therapeutically or nutritionally
effective amount" refers to a non-toxic, but sufficient amount of
an active agent, to achieve therapeutic or nutritional results in
treating or preventing a condition for which the active agent is
known to be effective or providing nutritional value to prevent
effects of malnutrition. It is understood that various biological
factors may affect the ability of a substance to perform its
intended task. Therefore, an "effective amount" or a
"therapeutically or nutritionally effective amount" may be
dependent in some instances on such biological factors.
Additionally, in some cases an "effective amount" or a
"therapeutically or nutritionally effective amount" may not be
achieved in a single dose. Rather, in some examples, an "effective
amount" or a "therapeutically or nutritionally effective amount"
can be achieved after administering a plurality of doses over a
period of time, such as in a pre-designated dosing regimen.
Further, while the achievement of therapeutic/nutritional effects
may be measured by a physician or other qualified medical personnel
using evaluations known in the art, it is recognized that
individual variation and response to treatments may make the
achievement of therapeutic or nutritional effects a subjective
decision. The determination of an effective amount is well within
the ordinary skill in the art of pharmaceutical and nutritional
sciences as well as medicine.
[0086] As used herein, the term "substantially" refers to the
complete or nearly complete extent or degree of a component, or an
action, characteristic, property, state, structure, item, or
result. The exact allowable degree of deviation from absolute
presence of such a component, or an action, characteristic,
property, state, structure, item, or result may in some cases
depend on the specific context. However, generally speaking,
"substantially" will be so near as to have the same overall result
as if absolute and total extent or degree were obtained. The use of
"substantially" is equally applicable when used in a negative
connotation to refer to the complete or near complete lack of a
component, or an action, characteristic, property, state,
structure, item, or result. For example, a composition that is
"substantially free of" a component would either completely lack
the component, or so nearly completely lack the component that the
effect would be the same as if it completely lacked the component.
In other words, a composition that is "substantially free of" an
ingredient or element may still actually contain such component as
long as there is no measurable effect thereof, for example, trace
amounts. As used herein, "essentially free" means a component, or
an action, characteristic, property, state, structure, item, or
result is not present or is not detectable.
[0087] The terms "treat" and "treatment" refer to both therapeutic
treatment and prophylactic or preventative measures, wherein the
object is to prevent or slow down (lessen) an undesired
physiological change, disorder or adverse health condition. For
purposes of this disclosure, beneficial or desired clinical results
include, but are not limited to, alleviation of symptoms,
diminishment of extent of the condition, stabilized (i.e., not
worsening) state of the condition, delay or slowing of progression
of the condition, amelioration or palliation of the condition, and
absence of condition (whether partial or total), whether detectable
or undetectable. "Treatment" can also mean prolonging survival as
compared to expected survival if not receiving treatment. Those in
need of treatment include those already with the condition or
disorder as well as those prone to have the condition or disorder
or those in which the condition or disorder is to be prevented.
[0088] The term "pharmaceutically acceptable salts" denotes salts
which are not biologically or otherwise undesirable.
Pharmaceutically acceptable salts include both acid and base
addition salts. The phrase "pharmaceutically acceptable" indicates
that the substance or composition must be compatible chemically
and/or toxicologically, with the other ingredients comprising a
formulation, and/or the mammal being treated therewith. The phrase
"pharmaceutically acceptable salt," as used herein, refers to
pharmaceutically acceptable organic or inorganic salts of a
molecule. A pharmaceutically acceptable salt may involve the
inclusion of another molecule that acts as a counterion. The
counterion may be any organic or inorganic moiety that stabilizes
the charge on the parent compound. Furthermore, a pharmaceutically
acceptable salt may have more than one charged atom in its
structure. Hence, a pharmaceutically acceptable salt can have one
or more charged atoms and/or one or more counterions. In the case
of L-cysteine, the hydrochloride salt form is preferred.
[0089] The phrase "single-use container" refers to a sealed
pharmaceutically prepared container holding a drug product in a
sterile environment that is intended to be used in a single
operation of transferring the entire contents or substantially
entire contents, wherein the transfer operation spans no more than
10-12 hrs, but often less than 8 hrs, or even six hours. It should
be recognized that the single-use container is generally
preservative-free and that if multiple transfers are attempted,
they should be completed in a short duration, i.e., less than about
8-10 hrs from the first breach of the sterile environment. In some
aspects the single-use container may be used to administer all of
its contents to one subject in need thereof. In some aspects the
single-use container may be used to administer its contents to more
than one subject in need thereof.
[0090] As used herein, the term "mixing" refers to admixing,
contacting, blending, stirring or allowing to admix, mix, blend,
stir and the like.
[0091] As used herein, the term "safe" refers generally to a
property of the compositions and methods described herein relative
to art method and compositions and/or to FDA regulatory
determination of the compositions and methods as part of a
therapeutically or nutritionally effective regimen. For example,
with respect to known L-Cysteine compositions, an Aluminum level of
greater than 300 ppb would be generally considered to render the
L-Cysteine product unsafe. Other examples with respect to safety
are described and discussed herein with respect to Aluminum,
pyruvate, Cystine, heavy metals, anions, and particulates.
[0092] Additional definitions are provided herein where
appropriate.
II. Compositions
[0093] In certain aspects, the subject matter described herein is
directed to a safe, stable L-cysteine composition for parenteral
administration, comprising:
[0094] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof in an amount from about 10 mg/mL to about
100 mg/mL; Aluminum (Al) in an amount from about 1.0 parts per
billion (ppb) to about 250 ppb;
[0095] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine;
[0096] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0097] a pharmaceutically acceptable carrier, comprising water;
[0098] headspace O.sub.2 that is from about 0.5% to 4.0% from the
time of manufacture to about 1 month from manufacture when stored
at room temperature;
[0099] dissolved oxygen present in the carrier in an amount from
about 0.1 parts per million (ppm) to about 5 ppm from the time of
manufacture to about 1 month from manufacture when stored at room
temperature;
[0100] wherein the composition is enclosed in a single-use
container having a volume of from about 10 mL to about 100 mL.
[0101] In certain aspects, the subject matter described herein is
directed to a safe, stable L-cysteine composition for parenteral
administration, comprising:
[0102] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof in an amount from about 10 mg/mL to about
100 mg/mL;
Aluminum (Al) in an amount from about 1.0 parts per billion (ppb)
to about 250 ppb;
[0103] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine;
[0104] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0105] a pharmaceutically acceptable carrier, comprising water;
[0106] headspace O.sub.2 that is from about 0.5% to 4.0% from the
time of manufacture to about 1 month from manufacture when stored
at room temperature;
[0107] dissolved oxygen present in the carrier in an amount from
about 0.1 parts per million (ppm) to about 5 ppm from the time of
manufacture to about 1 month from manufacture when stored at room
temperature;
[0108] optionally present can be one or more metals selected from
the group consisting of Lead from about 1.0 ppb to about 10 ppb,
Nickel from about 5 ppb to about 40 ppb, Arsenic from about 0.1 ppb
to 10 ppb, and Mercury from about 0.2 ppb to about 5.0 ppb;
[0109] wherein the composition is enclosed in a single-use
container having a volume of from about 10 mL to about 100 mL.
[0110] The Aluminum in a composition can be determined using any
known analytical method, such as those required by FDA regulations,
and can include atomic absorption and mass spectrometry. In certain
embodiments, the Aluminum that is present in the compositions is
present in an amount from about 1.0 ppb to about 250 ppb, or from
about 1.0 ppb to about 180 ppb, or from about 1.0 ppb to about 170
ppb, or from about 1.0 ppb to about 160 ppb, or from about 1.0 ppb
to about 150 ppb, or from about 1.0 ppb to about 130 ppb, or from
about 1.0 ppb to about 100 ppb, or from about 1.0 ppb to about 50
ppb, or from about 1.0 ppb to about 20 ppb.
[0111] In some embodiments the L-Cysteine and Aluminum are at a
ratio of from about 35 million:1 (i.e., about 35 million units of
L-Cysteine to 1 unit of Aluminum). In some embodiments the
L-Cysteine and Aluminum are at a ratio of about 4 million:1. In
some embodiments the L-Cysteine and Aluminum are at a ratio of
about 1.8 million:1 (i.e., about 1.8 million units of L-Cysteine to
1 unit of Aluminum). In some embodiments the L-Cysteine and
Aluminum are at a ratio of about 700,000:1 (i.e., about 700,000
units of L-Cysteine to 1 unit of Aluminum). In some embodiments the
L-Cysteine and Aluminum are at a ratio of about 300,000:1 (i.e.,
about 300,000 units of L-Cysteine to 1 unit of Aluminum). In some
embodiments the L-Cysteine and Aluminum are at a ratio of about
230,000:1 (i.e., about 230,000 units of L-Cysteine to 1 unit of
Aluminum). In some embodiments the L-Cysteine and Aluminum are at a
ratio of about 170,000:1 (i.e., about 170,000 units of L-Cysteine
to 1 unit of Aluminum). In some embodiments the L-Cysteine and
Aluminum are at a ratio of about 140,000:1 (i.e., about 140,000
units of L-Cysteine to 1 unit of Aluminum).
[0112] Thus, in some embodiments the L-Cysteine and Aluminum are at
a ratio of from about 35 million:1 (i.e., about 35 million units of
L-Cysteine to 1 unit of Aluminum) to about 1.8 million:1 (i.e.,
about 1.8 million units of L-Cysteine to 1 unit of Aluminum). In
some embodiments the L-Cysteine and Aluminum are at a ratio of from
about 4 million:1 (i.e., about 4 million units of L-Cysteine to 1
unit of Aluminum) to about 1.8 million:1 (i.e., about 1.8 million
units of L-Cysteine to 1 unit of Aluminum). In some embodiments the
L-Cysteine and Aluminum are at a ratio of from about 1.8 million:1
(i.e., about 1.8 million units of L-Cysteine to 1 unit of Aluminum)
to about 700,000:1 (i.e., about 700,000 units of L-Cysteine to 1
unit of Aluminum). In some embodiments the L-Cysteine and
[0113] Aluminum are at a ratio of from about 700,000:1 (i.e., about
700,000 units of L-Cysteine to 1 unit of Aluminum) to about
300,000:1 (i.e., about 300,000 units of L-Cysteine to 1 unit of
Aluminum). In some embodiments the L-Cysteine and Aluminum are at a
ratio of from about 300,000:1 (i.e., about 300,000 units of
L-Cysteine to 1 unit of Aluminum) to about 230,000:1 (i.e., about
230,000 units of L-Cysteine to 1 unit of Aluminum). In some
embodiments the L-Cysteine and Aluminum are at a ratio of from
about 230,000:1 (i.e., about 230,000 units of L-Cysteine to 1 unit
of Aluminum) to about 170,000:1 (i.e., about 170,000 units of
L-Cysteine to 1 unit of Aluminum). Thus, in some embodiments the
L-Cysteine and Aluminum are at a ratio of from about 170,000:1
(i.e., about 170,000 units of L-Cysteine to 1 unit of Aluminum) to
about 140,000:1 (i.e., about 140,000 units of L-Cysteine to 1 unit
of Aluminum). All subranges and individual values with increments
of 5,000 units are contemplated by the present disclosure. In some
embodiments, the unit of measure is nanograms. For example, in some
embodiments the L-Cysteine and Aluminum are at a ratio of from
about 4 million:1 nanograms (i.e., about 4 million nanograms of
L-Cysteine to 1 nanogram of Aluminum) to about 1.8 million:1
nanograms (i.e., about 1.8 million nanograms of L-Cysteine to 1
nanogram of Aluminum).
[0114] In certain embodiments, the compositions comprise Aluminum
in trace amounts, for example 1.0 ppb, but not more than 250 ppb
after storage at ambient temperature for a period of 12 months or
less, where the Aluminum comprises, from about 1.0 ppb to about 100
ppb of Aluminum from the container, from about 1.0 ppb to about 100
ppb of Aluminum from a cap of the container, from about 1.0 ppb to
about 100 ppb of Aluminum from the L-cysteine, and from about 1.0
ppb to about 20 ppb of Aluminum from the water.
[0115] In certain embodiments, the compositions comprise Aluminum
in an amount not more than 200 ppb after storage at ambient
temperature for a period of 12 months, wherein the Aluminum
comprises, from about 1.0 ppb to about 100 ppb of Aluminum from the
container, from about 1.0 ppb to about 100 ppb of Aluminum from a
cap of the container, from about 1.0 ppb to about 100 ppb of
Aluminum from the L-cysteine, and from about 1.0 ppb to about 20
ppb of Aluminum from the water. In certain embodiments, the
compositions comprise Aluminum in an amount not more than 200 ppb
after storage at ambient temperature for a period of 6 months,
where the Aluminum comprises, from about 1.0 ppb to about 100 ppb
of Aluminum from the container, from about 1.0 ppb to about 100 ppb
of Aluminum from a cap of the container, from about 1.0 ppb to
about 100 ppm of Aluminum from the L-cysteine, and from about 1.0
ppb to about 20 ppb of Aluminum from the water. In certain
embodiments, the compositions comprise Aluminum in an amount not
more than 200 ppb after storage at ambient temperature for a period
of 3 months, wherein the Aluminum comprises, from about 1.0 ppb to
about 100 ppb of Aluminum from the container, from about 1.0 ppb to
about 100 ppb of Aluminum from a cap of the container, from about
1.0 ppb to about 100 ppm of Aluminum from the L-cysteine, and from
about 1.0 ppb to about 20 ppb of Aluminum from the water.
[0116] In certain embodiments, the dissolved oxygen is present in
an amount from about 0.1 ppm to about 5.0 ppm, or from about 0.10
ppm to about 4.0 ppm, or from about 0.10 ppm to about 3.0 ppm, or
from about 0.10 ppm to about 2.0 ppm, or from about 0.11 ppm to
about 1.0 ppm. In particular, values of dissolved oxygen from about
0.4 ppm to about 3.8 ppm are preferred. For the sake of clarity and
the ease of discussion and measurement, these values are taken for
the L-Cysteine composition at the time of its manufacture (commonly
known as "time zero" data point), or during and up to 1 month from
time zero. Additional time points beyond the 1-month from time zero
data point are expected to provide similar dissolved oxygen
levels.
[0117] To achieve the above objective, as described herein,
numerous aspects for possible oxygen introduction into the
L-cysteine composition have been carefully studied and controlled.
For example, in some cases, the dissolved oxygen content in the
carrier can be reduced to at or below a predetermined level before
the L-cysteine is added to the carrier.
[0118] In some additional examples, reducing a level of dissolved
oxygen in the carrier can include blanketing a container for
housing the composition in an inert gas, such as nitrogen, argon,
or the like, prior to introducing the carrier or composition into
the container. In still other examples, reducing a level of
dissolved oxygen in the carrier can include bubbling the carrier or
composition with an inert gas, such as nitrogen, argon, or the
like, at ambient or reduced atmospheric pressure prior to and/or
during addition and mixing of L-cysteine. In some examples,
reducing a level of dissolved oxygen in the carrier can be
performed at an ambient or sub-ambient temperature. It is noted
that the reduction of dissolved oxygen in the carrier to at or
below a predetermined level can be accomplished without the
addition of a supplementary antioxidant, but is not required in the
methods and compositions described herein. Thus, the L-cysteine
composition for injection is free of a supplementary antioxidant.
As described elsewhere herein, attaining low and consistent
dissolved oxygen was achieved using the protocol with sampling as
set forth in Example 4.
[0119] The compositions have long-term stability. Thus, in certain
embodiments, the amounts of the components described herein are
amounts that are detected after the composition has been in
storage. The compositions will have been stored at room temperature
for less than a year, or for a year, or for more than a year. Such
timelines include, for example, for about 15 months, for about 18
months, for about 24 months. Or, alternatively, the storage time
could be for about 9 months, for about 7 months, for about 6
months, for about 5 months, for about 4 months, for about 3 months,
for about 2 months, for about 1 month, or for about 3 weeks.
Storage conditions are 25.degree. C./60% RH unless otherwise
indicated.
[0120] Useful concentrations of L-cysteine or a pharmaceutically
acceptable salt thereof and/or hydrate thereof in a compositions as
described herein include an amount from about 20 mg/mL to about 80
mg/mL, from about 30 mg/mL to about 70 mg/mL, from about 40 mg/mL
to about 60 mg/mL, from about 45 mg/mL to about 55 mg/mL, or an
amount of about 50 mg/mL, or from about 35 mg/mL to about 50 mg/mL,
or an amount of about 37.5 mg/mL. It is noted that the amounts of
L-cysteine disclosed herein, whether as a total mass or as a
concentration, are based on L-cysteine hydrochloride monohydrate or
the free base, as specified. Thus, where other forms of L-cysteine
are employed in the composition, the amount of the alternative form
included in the composition can be calculated based on an
equivalent amount of L-cysteine hydrochloride monohydrate rather
than the amount of the alternative form employed.
[0121] Thus, the stable L-cysteine composition can comprise total
amounts of L-cysteine from about 200 mg to about 4000 mg, or from
about 300 mg to about 700 mg, or from about 300 mg to about 400 mg.
For example, a 10 mL vial could be manufactured to contain about
350 mg of L-Cysteine. In certain embodiments, the L-cysteine
composition can comprise a total amount of L-cysteine from about
1200 mg to about 2000 mg. For example, a 50 mL container could be
manufactured to contain about 1800 mg of L-Cysteine. In another
embodiment, the total composition of an L-Cysteine composition
container may range from about 3000 mg to about 4000 mg. For
example, a 100 mL container could be manufactured to contain about
3500 mg of total L-Cysteine.
[0122] It has been found that the container in which the
compositions are held can affect the level of certain components.
In certain embodiments, the L-cysteine composition can be enclosed
in a single-use container. The container can have a variety of
volumes. Typically, the container can have a volume of from about
10 ml to about 100 ml. In some examples, the container can have a
volume of from about 10 ml to about 50 ml. In other examples, the
container can have a volume of from about 50 ml to about 100 ml. In
still other examples, the container can have a volume of about 10
ml or about 20 ml.
[0123] The container can be made of a variety of materials.
Non-limiting materials can include glass, a plastic (e.g.
polyethylene, polypropylene, polyvinyl chloride, polycarbonate,
etc.), the like, or a combination thereof provided that it can both
prevent oxygen penetration and minimize Aluminum, heavy metals and
anions contamination to the composition. Up to now, there has been
no guidance with regard to the compatibility of L-cysteine with
coated glass vials or that any vials could be used to provide
L-cysteine compositions having low levels of Aluminum.
[0124] Another confounding factor is the low pH of the L-Cysteine
product, which is less than 3.0 in certain embodiments. This low pH
can disrupt the plastic coating or silicon coating inside the glass
container and Aluminum, heavy metals and anions could leach during
the shelf life of the product, especially over prolonged storage of
the product. Therefore, up to now, the success of the product was
uncertain until the products described herein were manufactured and
studied in real time for prolonged periods as described herein.
[0125] It should be recognized that vials which are impermeable
with an internal coating, vials which are stored in a pouch that
protects the product from atmospheric oxygen ingress, and
relatively thick vials made of impermeable plastic or glass can be
suitable for the L-Cysteine product disclosed herein.
[0126] Vials which are stored in a pouch can be prepared in a
similar manner as described herein and then pouched in a plastic
material that is then sealed. The pouch may be kept under vacuum or
under an inert atmosphere. Methods for manufacturing such pouched
products, and materials for such manufacture are known in the
industry.
[0127] Relatively thick vials made of impermeable plastic are also
prepared in a similar manner as described herein. Such vials may be
composed of cyclic olefin materials of sufficient thickness to
prevent oxygen ingress over a reasonably long period of time, for
example 1 month, 2 months, 3 months, 6 months or 12 months. These
vials are packaged and supplied as such. Alternatively, these vials
can also be pouched as described above in plastic material that is
kept under vacuum or under an inert gas atmosphere. It is expected
that such pouching extends the shelf life of the product by at
least 1 month, or 2 months, or 3 months, or 6 months or longer.
[0128] In certain embodiments, the vials are made of glass with an
internal coating made of silicon dioxide, for example, Schott Type
1 Plus USP glass. The general thickness of the coating is presumed
to be at least 100-200 nanometers thickness. It is believed that
this level of thickness was sufficient to provide protection
against pH disruption while also preventing the migration of
Aluminum from the glass into the L-Cysteine product. Thus, in some
specific examples, the container can be an internally coated glass
container. In certain other embodiments the glass container is
internally coated with silicon dioxide of about 100 to about 200
nanometers.
[0129] In certain embodiments the Aluminum contribution from the
container may range from about 0.1 ppb to about 200 ppb. In certain
other embodiments the Aluminum contribution may range from about 1
ppb to about 150 ppb, from about 1 ppb to about 120 ppb, from about
1 ppb to about 100 ppb, from about 1 ppb to about 80 ppb, from
about 1 ppb to about 60 ppb, from about 1 ppb to about 50 ppb, from
about 1 ppb to about 40 ppb, from about 1 ppb to about 30 ppb, from
about 1 ppb to about 25 ppb, from about 1 ppb to about 20 ppb, from
about 1 ppb to about 15 ppb, from about 1 ppb to about 10 ppb, from
about 1 ppb to 5 ppb. In certain embodiments, the contribution
could be in subranges within the above ranges, for example, from
about 35 to 55 ppb, or from about 75 to about 140 ppb, in
increments of 5 ppb. All such ranges and subranges are contemplated
herein.
[0130] The containers are sealed with a suitable stopper made of
rubber, elastomeric polymers, or combinations thereof. In certain
embodiments the stoppers are coated with a special non-reactive
inert coating that minimizes interaction with drug product. For
example, some stoppers are coated with Teflon to prevent
drug-stopper interactions. One example of a specific coated stopper
is supplied by West Pharma and is called V10-F597W Stopper, 20 mm
Lyo, 4432/50 Gray, B2-TR Coating, Westar RS. This stopper is a
cross-linked mixture of high- and low-molecular weight silicone
oils that are cured through the application of UV rays and heat.
Because it is a spray-on coating applied to molded closures before
the trimming process, B2-Coating can be applied at various levels
on the bottom and top of closures. These specific stoppers are
preferred even though similar coating materials and methodology
applied to other types of stoppers could also work. The stoppers
are selected not only for their inertness vis-a-vis the drug
product but also for their minimal contribution to Aluminum levels
in the drug product.
[0131] In certain embodiments the Aluminum contribution from the
stopper may range from about 0.1 ppb to about 100 ppb. In certain
other embodiments the Aluminum contribution may range from about 1
ppb to about 90 ppb, from about 1 ppb to about 80 ppb, from about 1
ppb to about 70 ppb, from about 1 ppb to about 60 ppb, from about 1
ppb to about 50 ppb, from about 1 ppb to about 40 ppb, from about 1
ppb to about 30 ppb, from about 1 ppb to about 25 ppb, from about 1
ppb to about 20 ppb, from about 1 ppb to about 15 ppb, from about 1
ppb to about 10 ppb, from about 1 ppb to 5 ppb. In certain
embodiments, the contribution could be in subranges within the
above ranges, for example, from about 35 to 55 ppb, or from about
25 to about 75 ppb, in increments of 5 ppb. All such ranges and
subranges are contemplated herein.
[0132] In addition to the container and stopper, the drug substance
and excipients including water for injection may contribute
Aluminum to the drug product. Thus, in one aspect the Aluminum
contribution from the drug substance may range from about 0.1 ppb
to about 70 ppb. In certain other embodiments the Aluminum
contribution may range from about 1 ppb to about 60 ppb, from about
1 ppb to about 50 ppb, from about 1 ppb to about 40 ppb, from about
1 ppb to about 30 ppb, from about 1 ppb to about 25 ppb, from about
1 ppb to about 20 ppb, from about 1 ppb to about 15 ppb, from about
1 ppb to about 10 ppb, from about 1 ppb to 5 ppb. In certain
embodiments, the contribution could be in subranges within the
above ranges, for example, from about 35 to 55 ppb, or from about
75 to about 140 ppb, in increments of 5 ppb. All such ranges and
subranges are contemplated herein.
[0133] The water for injection may contribute Aluminum from about
0.1 ppb to about 20 ppb. In certain embodiments the Aluminum
contribution may range from about 1 ppb to about 15 ppb, from about
1 ppb to about 12 ppb, from about 1 ppb to about 10 ppb, from about
1 ppb to about 8 ppb, from about 1 ppb to about 6 ppb, from about 1
ppb to about 5 ppb, from about 1 ppb to about 4 ppb, from about 1
ppb to about 3 ppb, from about 1 ppb to about 2.5 ppb, from about 1
ppb to about 2 ppb, from about 1 ppb to about 1.5 ppb. In certain
embodiments, the contribution could be in subranges within the
above ranges, for example, from about 5 to 7.5 ppb, or from about
10.5 to about 15.0 ppb, in increments of 0.5 ppb. All such ranges
and subranges are contemplated herein.
[0134] In summary, to lower the Aluminum level to even greater
extent as described herein, the container, the stopper, the drug
substance, the water for injection, and any other excipients can be
chosen such that the Aluminum concentration in the drug product is
from about 1.0 ppb to about 250 ppb, or as described in the other
embodiments provided herein.
[0135] Advantageously, in certain embodiments, the compositions
maintain cystine levels for extended periods, and/or are
substantially free or essentially free of cystine precipitate.
However, it is noted that where cystine is present in the
L-cysteine composition it is not necessarily dissolved. For
example, in some cases, it can be present in the composition as an
undissolved particle.
[0136] Where the L-cysteine composition includes cystine, it can
typically be present in relatively small amounts compared to
L-cysteine. In certain embodiments, cystine is present in the
composition in an amount not more than 2.0 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 1.0 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 0.5 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 0.4 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 0.3 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 0.2 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, cystine is present in the
composition in an amount not more than 0.1 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months.
[0137] Further, in certain embodiments, cystine can be present in
the L-cysteine composition, but in an amount not more than 2.0 wt %
relative to L-cysteine after storage at ambient temperature for a
period of 3 months. In certain embodiments, cystine can be present
in the L-cysteine composition, but in an amount not more than 2.0
wt % relative to L-cysteine after storage at ambient temperature
for a period of 3 months. In some embodiments, cystine can be
present in the L-cysteine composition in an amount from about 0.001
wt % to about 2.0 wt % relative to the amount of L-cysteine present
in the composition. In some embodiments, cystine can be present in
the L-cysteine composition in an amount from about 0.005 wt % to
about 0.5 wt % relative to the amount of L-cysteine present in the
composition. In some embodiments, cystine can be present in the
L-cysteine composition in an amount from about 0.05 wt % to about
1.0 wt % relative to the amount of L-cysteine present in the
composition. In some embodiments, L-cystine can be present, but in
an amount that is either not detectable or that is below a limit of
quantitation using a standard testing procedure, such as a
validated test method for detecting cystine.
[0138] Advantageously, in certain embodiments, the compositions
maintain pyruvic acid levels for extended periods, and/or are
substantially free or essentially free of pyruvic acid. When
present, pyruvic acid is typically present in a relatively small
amount compared to L-cysteine. In certain embodiments, pyruvic acid
is present in the composition in an amount not more than 2.0 wt %
relative to L-cysteine after storage at ambient temperature for a
period of 6 months. In certain embodiments, pyruvic acid is present
in the composition in an amount not more than 1.0 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, pyruvic acid is present in the
composition in an amount not more than 0.5 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, pyruvic acid is present in the
composition in an amount not more than 0.4 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, pyruvic acid is present in the
composition in an amount not more than 0.3 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, pyruvic acid is present in the
composition in an amount not more than 0.2 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months.
[0139] In certain embodiments, pyruvic acid is present in the
composition in an amount not more than 0.1 wt % relative to
L-cysteine after storage at ambient temperature for a period of 6
months. In certain embodiments, pyruvic acid can be present in the
L-cysteine composition, but in an amount not more than 2.0 wt %
relative to L-cysteine after storage at ambient temperature for a
period of 3 months. In certain embodiments, pyruvic acid can be
present in the L-cysteine composition, but in an amount not more
than 2.0 wt % relative to L-cysteine after storage at ambient
temperature for a period of 6 months. In some embodiments, pyruvic
acid can be present in the L-cysteine composition in an amount from
about 0.001 wt % to about 2.0 wt % relative to the amount of
L-cysteine present in the composition. In some embodiments, pyruvic
acid can be present in the L-cysteine composition in an amount from
about 0.005 wt % to about 0.5 wt % relative to the amount of
L-cysteine present in the composition. In some embodiments, pyruvic
acid can be present in the L-cysteine composition in an amount from
about 0.05 wt % to about 1.0 wt % relative to the amount of
L-cysteine present in the composition. In some embodiments, pyruvic
acid can be present, but in an amount that is either not detectable
or that is below a limit of quantitation using a standard testing
procedure, such as a validated test method for detecting pyruvic
acid.
[0140] As discussed above, to achieve safe method and compositions,
it is beneficial to further understand which other components are
present beyond Aluminum and pyruvic acid, and control their amounts
as well. Because preterm infants could be exposed to L-Cysteine for
potentially longer periods, and their main source of L-Cysteine is
through parenteral administration, careful consideration should be
given to exposure to other potentially unsafe compounds that may
leach out of the container or stopper in amounts greater than what
are considered safe limits. Examples include certain volatile
compounds, certain heavy elements, and certain anions.
[0141] Daily acceptable limits are known for these potentially
unsafe compounds. However, because the L-Cysteine Injection is used
to infuse into preterm and term infants and those elderly that are
critically ill will compromised renal functions, and sometimes for
periods that exceed more than a few days, just meeting the daily
acceptable limits may not be sufficient. Every effort must be made
to reduce the levels to as low as practicable. The L-Cysteine
compositions presented herein provide in some embodiments about
one-half of the daily acceptable limits; in some embodiments, about
one-fourth of the daily acceptable limits; in some embodiments,
about one-fifth of the daily acceptable limits; in some
embodiments, about one-sixth of the daily acceptable limits.
[0142] The anions that are desirable to control are: Iodide and
Fluoride. The acceptable limit for Iodide is about 20 ppm or less.
The acceptable limit for Fluoride is about 30 ppm or less. The
L-Cysteine compositions provided herein show Iodide concentrations
of less 20 ppm and Fluoride concentrations of less than 30 ppm when
measured at any time from the day of manufacture through its
shelf-life of 6 months, or 12 months, or 18 months, or 24 months,
when stored under Room Temperature Conditions. In some embodiments,
the L-Cysteine compositions provide from about 1.0 ppm to 20 ppm of
Iodide; in some embodiments, from about 1.0 ppm to about 15 ppm; in
some embodiments, from about 1.0 ppm to about 10 ppm; and in some
embodiments, from about 1.0 ppm to about 5 ppm. In some
embodiments, the L-Cysteine compositions provide from about 1.0 ppm
to 20 ppm of Fluoride; in some embodiments, from about 1.0 ppm to
about 15 ppm; in some embodiments, from about 1.0 ppm to about 10
ppm; and in some embodiments, from about 1.0 ppm to about 5 ppm.
Methods for evaluating the anions and the results are provided in
Example 8.
[0143] As noted above, several elements may leach or be extracted
out into the L-Cysteine drug product, thereby presenting a
potential safety/toxicity concern to subjects that require
L-Cysteine parenteral administration. Art-known methods may be used
to evaluate the elemental levels. Inductively-coupled plasma mass
spectral method is one such highly specific method. Example 9
provides the data generated by using ICP-MS technique. As shown in
Example 9, there are over thirty elements that are generally known
to present safety/toxicity concerns. The Table 22 provides the
daily allowable limit for all of these elements, and the observed
levels in the present L-Cysteine compositions. The daily allowable
limit for some elements are relatively high, whereas for other
elements they are relatively very low. For example, Molybdynum has
the level of 14,500 ppb approximately, whereas Cadmium has about 19
ppb.
[0144] For purposes of monitoring the L-Cysteine compositions for
the elements of concern, in one aspect, the levels of Mercury,
Lead, Nickel and Arsenic are of significance. Therefore, in one
aspect, the L-Cysteine compositions presented herein have further
improved safety because they provide these elements at amounts far
less than the daily allowable limits. Targeted daily allowable
limits include 48 ppb for Lead, 29 ppb for Mercury, 194 ppb for
Nickel, and 174 ppb for Arsenic.
[0145] The L-Cysteine compositions described herein provide from
about 1 ppb to 10 ppb of Lead; in some embodiments, from about 1
ppb to about 8 ppb; in some embodiments, from about 1 ppb to about
7 ppb; or in some embodiments, from about 1 ppb to about 5 ppb.
when measured at any time from the day of manufacture through its
shelf-life of 6 months, or 12 months, or 18 months, or 24 months,
when stored under Room Temperature Conditions.
[0146] With respect to Mercury, the L-Cysteine compositions
described herein provide from about 0.1 ppb to 10 ppb of Mercury;
in some embodiments, from about 0.1 ppb to about 8 ppb; in some
embodiments, from about 0.1 ppb to about 7 ppb; or in some
embodiments, from about 0.1 ppb to about 5 ppb. when measured at
any time from the day of manufacture through its shelf-life of 6
months, or 12 months, or 18 months, or 24 months, when stored under
Room Temperature Conditions.
[0147] With respect to Nickel, the L-Cysteine compositions
described herein provide from about 1 ppb to 50 ppb of Nickel; in
some embodiments, from about 1 ppb to about 40 ppb; in some
embodiments, from about 1 ppb to about 30 ppb; or in some
embodiments, from about 1 ppb to about 25 ppb; or in some
embodiments from about 1 ppb to about 20 ppb, when measured at any
time from the day of manufacture through its shelf-life of 6
months, or 12 months, or 18 months, or 24 months, when stored under
Room Temperature Conditions.
[0148] With respect to Arsenic, the L-Cysteine compositions
described herein provide from about 0.1 ppb to 60 ppb of Arsenic;
in some embodiments, from about 0.1 ppb to about 50 ppb; in some
embodiments, from about 0.1 ppb to about 40 ppb; in some
embodiments, from about 0.1 ppb to about 30 ppb; in some
embodiments, from about 0.1 ppb to about 25 ppb; or in some
embodiments from about 0.1 ppb to about 20 ppb; in some
embodiments, from about 0.1 ppb to about 15 ppb; in some
embodiments, from about 0.1 ppb to about 10 ppb; or in some
embodiments, from about 0.1 ppb to about 5.0 ppb, when measured at
any time from the day of manufacture through its shelf-life of 6
months, or 12 months, or 18 months, or 24 months, when stored under
Room Temperature Conditions.
[0149] In some embodiments, the Arsenic, Mercury, Lead and other
elements may be extracted from the container or from the stopper.
In one specific embodiment, the extracted out amount of Arsenic,
Mercury, Lead, and Nickel combined from the stopper is 100 ppb or
less. In other embodiments, the extracted amount of Arsenic,
Mercury, Lead, and Nickel combined from the stopper is from about
10 to about 50 or from about 10 to about 100 ppb.
[0150] It should be recognized that in some instances the amount of
a specific element present in the L-Cysteine compositions described
herein may be below the Limit of Quantitation (LOQ). In those
instances, for purposes of this disclosure and claims made herein,
the compositions may be considered to contain the lowest level
described in the preceding paragraphs. For example, when Arsenic is
determined to be below the LOQ, the Arsenic amount may be
considered to be at 0.1 ppb. Therefore, all such instances where
the compositions show amounts below the LOQ are within the
contemplation of this disclosure.
[0151] In certain embodiments, the compositions further comprise
within the container, headspace gas that includes oxygen in an
amount of from about 0.5% v/v to about 5.0% v/v, or from about 0.5%
v/v to about 4.0% v/v, or from about 0.5% v/v to about 3.5% v/v,
from about 0.5% v/v to about 3.0% v/v, or from about 0.5% v/v to
about 2.5% v/v, or from about 0.5% v/v to about 2.0% v/v, or from
about 0.5% v/v to about 1.5% v/v, or from about 0.5% v/v to about
1.0% v/v, or in some cases from about 0.1% v/v to about 0.5% v/v,
or from about 0.1% v/v to about 0.4% v/v, or from about 0.1% v/v to
about 0.3% v/v, or from about 0.1% v/v to about 0.2% v/v. For the
sake of clarity and the ease of discussion and measurement, these
values are taken for the L-Cysteine composition at the time of its
manufacture ("tine zero" data point), or during and up to 1 month
from time zero. Additional time points beyond the 1-month from time
zero data point may provide similar headspace oxygen levels.
[0152] Without wishing to be bound by theory, the dissolved oxygen
levels and the head space oxygen levels within a sealed container
of L-Cysteine compositions described herein may reach an
equilibrium at some time point during its shelf-life. Such
equilibrium may be maintained for a very short time, i.e., for a
few seconds, or for a very long time, i.e., for several months.
Such equilibrium may on occasion be disturbed by simple agitation.
Therefore, it should be recognized that dissolved oxygen levels and
headspace oxygen levels may fluctuate from one time point to
another in terms of absolute numbers. However, the numbers are
expected to stay within the ranges disclosed herein. Occasionally,
one number (e.g., dissolved oxygen) may exceed or fall out of a
certain range (e.g., from about 05 to about 3.0 PPM) at a 15-day
time point, but may fall within that range at some other time point
(e.g., 30 day time point, or later). Therefore, in some aspects,
the ranges, subranges, and specific data points disclosed and
discussed herein are valid and suitable for time points beyond the
time zero and 1-month time points. In one aspect, the time points
could be extended to 2-months, 3-months, 6-months, 9-months,
12-months, 15-months, 18-months, and 24 months.
[0153] In some aspects, the total amount of oxygen in the sealed
container may be an appropriate measure to evaluate the stability
of the L-Cysteine compositions herein. For example, the total
amount of oxygen within the container may be arrived at by adding
up the amount of dissolved oxygen in the carrier and the amount of
head space oxygen. These values can also be expressed independently
in separate units (i.e., dissolved oxygen as ppm and head space
oxygen as % v/v). An example would be an L-Cysteine composition
that contains a dissolved oxygen level of from about 0.1 ppm to 4.0
ppm and a head space oxygen level of about 0.5% v/v to about 4.0%
v/v.
[0154] The amount of oxygen present in the headspace of the
container can be controlled by filling the headspace with an inert
gas, such as nitrogen or argon. Alternatively, the head space
oxygen may be controlled by vacuum operation without using an inert
gas. In another aspect, the head space oxygen may be controlled by
a combination of vacuum operation and inert gas overlay. In one
particular aspect, the head space oxygen is controlled by repeated
pulses of vacuum and inert gas overlay in tandem such that the
process may start first with vacuum operation followed by inert gas
overlay followed by vacuum operation. The combination of vacuum
operation and inert gas overlay (or inert gas overlay and vacuum
operation) is considered one pulse when both steps are used
together. A typical head space control operation may comprise from
one to eight pulses. Typically, there could be two, three, four, or
five pulses. Each pulse could last from about one tenth of one
second to five seconds or from five to fifteen seconds when
conducted by automated high-speed equipment custom designed for
this specific purpose. In some embodiments, the pulse may last from
about 0.1 to about 2.0 seconds. In some embodiments, the pulse may
last from about 0.1 to about 1.0 seconds, or from about 0.1 to
about 0.4 seconds. When done using manual methods, each pulse could
take up to 30-60 seconds or longer. Such a manual process is
described in more detail in Examples 1 and 4. Alternatively, a more
automated process that was developed by the current inventors is
described in Example 5.
[0155] In certain embodiments, the compositions are part of a total
parenteral nutrition regimen. The L-cysteine compositions described
herein can be admixed with amino acid solutions, such as
crystalline amino acid injection, for example, commercially
available TRAVASOL.RTM. and TRAVASOL E.RTM..
[0156] In certain aspects, the subject matter described herein is
directed to a safe, stable composition from about 100 mL to about
1000 mL for administration via a parenteral infusion within about
24 to about 48 hours of admixture, comprising a mixture of a
composition of L-Cysteine described herein; and an amino acid
composition that is essentially free of L-Cysteine comprising one
or more amino acids selected from the group consisting of: leucine,
isoleucine, lysine, valine, phenylalanine, histidine, threonine,
methionine, tryptophan, alanine, arginine, glycine, proline,
serine, and tyrosine.
[0157] In certain embodiments, the subject matter described herein
is directed to a stable TPN composition for infusion,
comprising:
[0158] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof;
[0159] Aluminum in an amount from about 10 parts per billion (ppb)
to about 80 ppb;
[0160] cystine in an amount from about 0.001 wt % to about 2.0 wt %
relative to L-cysteine;
[0161] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0162] one or more amino acids selected from the group consisting
of: leucine, isoleucine, lysine, valine, phenylalanine, histidine,
threonine, methionine, tryptophan, alanine, arginine, glycine,
proline, serine, and tyrosine;
[0163] a pharmaceutically acceptable carrier, comprising water,
[0164] wherein, the amounts are from about 100 mL to about 1,000 mL
and the total aluminum delivered by the said composition does not
exceed about 4-5 mcg/kg/day. In certain embodiments, the amounts
include 150 mL, 200 mL, 250 mL, 300 mL, 350 mL, 400 mL, 450 mL, 500
mL, 550 mL, 600 mL, 650 mL, 700 mL, 750 mL, 800 mL, 850 mL, 900 mL
and 950 mL.
[0165] In certain embodiments, the stable composition for infusion
comprises one or more amino acids selected from the group
consisting of leucine, isoleucine, lysine, valine, phenylalanine,
histidine, threonine, methionine, tryptophan, alanine, arginine,
glycine, proline, serine, and tyrosine. In certain embodiments, the
composition includes all of these. In certain embodiments, 500 mg
of L-Cysteine is admixed with 12.5 gram of crystalline amino acid
injection, such as that present in 250 mL of 5% crystalline amino
acid injection. In some aspects, 15 mg of L-Cysteine is admixed
with one gram of amino acids. In some other aspect, 40 mg of
L-Cysteine is admixed with one gram of amino acids. Depending on
the needs of the subject, based on specific characteristics such as
age, weight, and physiological factors such as renal function, the
dose may be adjusted at or within these ranges of 15-40 mg of
L-Cysteine per gram of amino acids. See, for example, Tables 1-2
above. Thus, the pharmaceutical compositions comprising L-Cysteine
can be formulated, dosed and administered in a fashion, i.e.,
amounts, concentrations, schedules, course, and vehicles,
consistent with good medical practice. The "therapeutically and
nutritionally effective amount" of the compound to be administered
will be governed by such considerations.
[0166] In certain embodiments, the compositions are essentially
free of supplementary antioxidant. As used herein, this refers to
the absence of any substance that is added to the compositions
specifically as an antioxidant. Naturally occurring antioxidants
may still be present.
[0167] In certain embodiments, the compositions that comprise one
or more of the above amino acids are essentially free of dextrose.
However, in certain embodiments, the compositions that comprise one
or more of the above amino acids further comprise a sugar.
[0168] In certain embodiments, the pH of the compositions is about
1.0 to about 2.5, or about 1.6 to about 2.0, or about 1.6, or about
1.7, or about 1.8, or about 1.9 or about 2.0. For administration,
the pH is generally adjusted by admixing with other components to a
pH of about 6.0 to about 8.0, but generally around 7.0. In certain
embodiments, the compositions are essentially free of a buffer. In
certain embodiments, the compositions further comprise a
buffer.
[0169] In particular embodiments, the subject matter described
herein is directed to a stable L-cysteine composition for injection
that can be useful for treatment of a variety of conditions, such
as those described above. In further detail, L-cysteine can be
administered in a variety of forms, such as the free base,
L-cysteine hydrochloride, a pharmaceutically acceptable salt
thereof (e.g. sodium salt, calcium salt, etc.), a hydrate thereof,
the like, or a combination thereof. In some specific examples,
L-cysteine can be included in the L-cysteine composition for
injection as L-cysteine hydrochloride monohydrate.
[0170] In particular embodiments, the subject matter described
herein is directed to a stable L-cysteine composition for
injection, comprising:
[0171] about 34.5 mg/mL of L-cysteine free base, or a
pharmaceutically acceptable salt thereof and/or hydrate
thereof;
[0172] Aluminum in an amount of 130 ppb or below;
[0173] water;
[0174] wherein the composition is enclosed in a single-use
container having a volume of from 10 mL to 100 mL, and is stable
for 9 months or less.
[0175] In certain embodiments, the stable, safe L-cysteine
composition can consist essentially of L-cysteine, water, Aluminum
in an amount of less than 200 ppb, cystine in an amount from about
0.001 wt % to about 2 wt % relative to L-cysteine, pyruvic acid in
an amount from about 0.001 wt % to about 2 wt % to L-cysteine,
headspace oxygen that is less than 4.0% and dissolved oxygen from
about 0.1 ppm to about 1 ppm. Other trace components or excipients
do not materially affect the basic and novel characteristics of
composition unless otherwise indicated, for example, undesirable
anions and heavy metals.
[0176] The pharmaceutical composition (or formulation) for
application may be packaged in a variety of ways depending upon the
method used for administering the drug. Generally, an article for
distribution includes a container having deposited therein the
pharmaceutical formulation in an appropriate form. The container
may also include a tamper-proof assemblage to prevent indiscreet
access to the contents of the package. In addition, the container
has deposited thereon a label that describes the contents of the
container. The label may also include appropriate warnings, more
specifically about the Aluminum content of the L-Cysteine
composition. For example, the label may indicate that the Aluminum
in the container may be at 100 ppb or 100 mcg/L. In another
embodiment, the label may indicate that the Aluminum in the
container may be at 120 ppb or 120 mcg/L. In some specific
embodiments, the Aluminum level may be described as not more than
120 ppb, or not more than 120 mcg/L, or NMT 120 ppb, or NMT 120
mcg/L. In addition to the label, the labeling associated with the
L-Cysteine product may have the same description of Aluminum.
[0177] It should be understood that, as is customary in the
pharmaceutical arts, the phrases "NMT" or "not more than"
represents the upper limit, but also is understood not to mean that
the value is zero or even can be zero. For example, a statement
that the Aluminum levels are NMT 120 ppb is not understood by the
practitioners in the art that the Aluminum levels are at zero ppb
in that particular vial bearing that label. Pharmacists and other
health care professionals instead would interpret for purposes of
calculating the Aluminum content of a TPN preparation using that
specific L-Cysteine vial that the Aluminum levels are at 120 ppb so
that, even if the actual amount is lower than the 120 ppb in the
product, they err on the conservative side. This is the custom in
the pharmaceutical industry developed and practiced to safeguard
the health of patients. If indeed the label is intended to convey
with certainty that the actual Aluminum level is zero ppb, the
label then would state that fact or indicate that the product is
free of Aluminum.
[0178] Similarly, any numerical value expressed as "less than" is
intended to convey that the value is below that certain numerical
value, including, as the case may be zero. For example, when it is
stated herein that Aluminum levels are less than about 20 ppb, it
is understood that in some embodiments the Aluminum can be, but not
necessarily in all cases, anywhere from zero to about 19 ppb. It is
also understood that this may, but not necessarily in all cases,
encompass those situations where the levels are below quantitation
limit, but the presence of Aluminum is detectable. In those cases
where the Aluminum (or any other measured material generally) where
the material is detectable but is below the level of quantitation,
that numerical value can be considered for example as being about
1.0 (for Aluminum) or 0.001 (for Cystine or Pyruvic acid), or 1.0
ppb (for elements) or 1.0 ppm (for iodide or fluoride). Unless an
actual analysis is made of the product and a specific number is
determined, there is no certainty of the actual value. The US FDA
does not require this precision in the labeling on a
product-by-product or even batch-by-batch because that is
impracticable in a commercial supply chain setting for drug
products.
[0179] Thus, the phrases "NMT" or "not more than" or "less than"
are terms of art in the pharmaceutical industry. Those in the
industry do not assume these terms necessarily represent zero in
all cases, even though that is a possibility. When calculating the
Aluminum amounts for purposes of preparing parenteral nutrition
products the artisan never assumes the Aluminum levels are zero in
order to safeguard the patient health. Accordingly, this present
disclosure and the claims derived therefrom are to be read and
understood in light of this custom and practice in the art.
[0180] As mentioned above, the L-cysteine compositions for infusion
may optionally be mixed with pharmaceutically acceptable
excipients, also described in Remington's Pharmaceutical Sciences
(1980) 16.sup.th edition, Osol, A. Ed., Mack Publishing Co.,
Easton, Pa.
[0181] As noted above, the diluted L-cysteine composition for
infusion can typically have a pH of from about 5.0 to about 8.0, or
from about 6.0 to about 7.0. However, dilution and administration
of the L-cysteine composition for infusion will typically be
overseen by a licensed medical professional, who may recommend a pH
outside of the ranges recited herein under certain circumstances.
Additionally, the diluted L-cysteine composition for infusion can
typically have a tonicity of from about 250 milliosmoles/liter
(mOsmol/L) to about 1,000 mOsmol/L, or more, or of from about 350
mOsmol/L to about 475 mOsmol/L. However, dilution and
administration of the L-cysteine composition for infusion will
typically be overseen by a licensed medical professional, who may
recommend a tonicity outside of the ranges recited herein under
certain circumstances.
III. Methods
[0182] The subject matter described herein is directed to methods
of treating a subject having an adverse health condition that is
responsive to L-cysteine administration. The methods can include
diluting the stable L-cysteine composition described herein with an
intravenous fluid to prepare a diluted L-cysteine composition for
infusion. The methods can further include parenterally
administering the diluted L-cysteine composition to provide a
therapeutically effective dose of L-cysteine or a pharmaceutically
acceptable salt thereof and/or hydrate thereof to the subject in a
therapeutically effective dosing regimen.
[0183] In certain embodiments, the subject matter described herein
is directed to a method of reducing Aluminum administration from a
total parenteral nutrition regimen comprising L-cysteine, the
method comprising, mixing a composition comprising L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof
comprising:
[0184] Aluminum in an amount from about 1.0 parts per billion (ppb)
to about 250 ppb or from about 10 ppb to about 80 ppb;
[0185] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine; and
[0186] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0187] with a composition comprising one or more amino acids
selected from the group consisting of: leucine, isoleucine, lysine,
valine, phenylalanine, histidine, threonine, methionine,
tryptophan, alanine, arginine, glycine, proline, serine, and
tyrosine; and
[0188] a pharmaceutically acceptable carrier, comprising water, to
form a composition for infusion of about 100 mL to about 1000
mL,
[0189] wherein the Aluminum provided in said parenteral nutrition
regimen is from about 1-2 to about 4-5 micrograms/kg/day.
[0190] In certain aspects, the compositions and methods described
herein are directed to methods of administering L-Cysteine together
with a composition for parenteral nutrition, comprising:
[0191] diluting a stable L-cysteine composition for injection as
described herein with a parenteral nutrition composition to form a
mixture; and
[0192] parenterally administering the mixture to a subject in need
thereof in a therapeutically and/or nutritionally effective dose.
In one aspect, the subject is a neonatal weighing less than 2
kilos. In another aspect, the subject is a pediatric patient that
is from about 0.2 kilos to about 20 kilos. In another aspect, the
subject is an adult requiring parenteral nutrition.
[0193] In certain embodiments, the subject matter described herein
is directed to a method of reducing Aluminum administration from a
parenteral nutrition regimen comprising L-cysteine, comprising:
[0194] administering to a subject a composition comprising
L-cysteine or a pharmaceutically acceptable salt thereof and/or
hydrate thereof;
[0195] Aluminum in an amount from about 10.0 parts per billion
(ppb) to about 250 ppb, or from about 10 ppb to about 80 ppb;
[0196] cystine in an amount from about 0.01 wt % to about 2.0 wt %
relative to L-cysteine; pyruvic acid in an amount from about 0.01
wt % to about 2.0 wt % relative to L-cysteine;
[0197] one or more amino acids selected from the group consisting
of: leucine, isoleucine, lysine, valine, phenylalanine, histidine,
threonine, methionine, tryptophan, alanine, arginine, glycine,
proline, serine, and tyrosine,
[0198] a pharmaceutically acceptable carrier, comprising water,
wherein, the amounts are about 100 mL to about 1,000 mL,
[0199] wherein the Aluminum administered to said subject is reduced
compared to administration of a standard parenteral composition
comprising L-cysteine and Aluminum at a range of from about 900 ppb
to about 5,000 ppb.
[0200] In certain embodiments, the methods provide that the
reduction in the amount of Aluminum administered is relative to the
amount of Aluminum in a L-cysteine injection composition having
more than 500 ppb Aluminum, or more than 250 ppb Aluminum. The
relative reduction in Aluminum can be up to 90%, up to 80%, up to
70%, up to 60%, up to 50%, up to 40%, up to 30%, up to 20%, up to
10%, or up to 5%, as compared to the amount of Aluminum
administered with a L-cysteine composition having more than 500 ppb
Aluminum, or more than 250 ppb Aluminum. In certain embodiments,
the reduction occurs over the span of a day, a week, a month or the
duration of the TPN regimen.
[0201] In certain aspects, the subject matter described herein is
directed to methods of treating a subject having an adverse health
condition that is responsive to L-cysteine administration,
comprising:
[0202] diluting a stable L-cysteine composition as described herein
with an intravenous fluid to prepare a diluted L-cysteine
composition for infusion; and
[0203] infusing the diluted L-cysteine composition for infusion to
a subject to provide a therapeutically effective dose of L-cysteine
or a pharmaceutically acceptable salt thereof and/or hydrate
thereof to the subject in a therapeutically effective dosing
regimen.
[0204] In certain embodiments, the method of treating a subject
having an adverse health condition that is responsive to L-cysteine
administration further comprises, before the diluting step,
admixing the stable L-cysteine composition with an amino acid
solution, such as, crystalline amino acid injection. In this
aspect, the methods comprise diluting with an intravenous fluid the
stable L-cysteine composition admixed with an amino acid solution,
wherein the fluid comprises dextrose.
[0205] In certain embodiments, the adverse health condition is the
lack of a necessary enzyme in the trans-sulfuration pathway that
converts methionine to L-cysteine. Other adverse health conditions
include inadequate absorption resulting from short bowel syndrome;
gastrointestinal fistula; bowel obstruction; prolonged bowel rest;
severe malnutrition; significant weight loss and/or
hypoproteinaemia when enteral therapy is not possible; other
disease states or conditions in which oral or enteral feeding are
not an option.
[0206] For most preterm infants, the administration should be
considered as a short-term bridge to provide nutritional support
until full enteral nutrition can be provided. Such instances
include: Immediately after birth, to provide essential nutrition as
enteral feeds are commenced and advanced, and/or during periods of
acute gastrointestinal malfunction (eg, due to septic ileus or
necrotizing enterocolitis).
[0207] In certain embodiments, the administering is a single daily
dose, or multiple daily doses, or is administered in accordance
with a TPN regimen, for example, the dosing can be over a day,
several days, a week or several weeks, a month or several
months.
[0208] In certain embodiments, the subject is an infant or pre-term
infant from newborn until about 6 months of age. As presented in
Tables 1 and 2 above, the subjects can be from a pre-term infant to
an adult that is in need of L-Cysteine supplementation. Thus, the
subject can be a subject "in need of" the methods of described
herein, for example, in need of the therapeutic effects or
prophylactic benefits of the methods. In certain embodiments, the
subject is a subject in need of a total parenteral nutrition (TPN)
regimen.
[0209] In certain embodiments, the intravenous fluid is selected
from the group consisting of isotonic saline, glucose solution,
glucose saline, dextrose solution, crystalline amino acid solution,
lipids, and combinations thereof.
[0210] In certain embodiments, the L-cysteine is L-cysteine
hydrochloride monohydrate.
[0211] In certain embodiments, the diluted L-cysteine composition
for infusion is typically administered via intravenous infusion.
The selection of administration rate and site of infusion (i.e.,
via a peripheral or central vein) are within the ordinary skill in
the art of medicine, pharmaceutical, nursing, and nutritional
sciences.
[0212] The diluted L-cysteine composition for infusion can be
administered until a therapeutically effective dose is achieved. In
some examples, a therapeutically effective dose of L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof can
be from about 0.01 mg to about 2.0 mg L-cysteine. Again,
therapeutically effective doses can depend on whether the patient
is a pediatric patient or an adult patient. For example, for
preterm or term infants less than 1 month of age, the
therapeutically effective dose is about 45 to 60 mcg/kg/day. For
pediatric patients 1 month to less than 1 year of age, the
therapeutically effective dose is 30 to 45 mcg/kg/day. For
pediatric patients 1 year to 11 years of age, the therapeutically
effective dose is about 15 to 30 mcg/kg/day. For pediatric patients
12 years to 17 years of age, the therapeutically effective dose is
about 4 to 7.5 mcg/kg/day. For adults, i.e., stable patients, the
therapeutically effective dose is 4 to 5 mcg/kg/day. For adults
that are critically ill, the therapeutically effective dose is 7.5
to 10 mcg/kg/day.
[0213] The number of doses given daily can vary as desired or
needed per the therapeutically effective dosing regimen. In some
examples, the therapeutically effective dosing regimen can include
daily administration of the diluted L-cysteine composition. In
other examples, the therapeutically effective dosing regimen can
include twice-daily administration of the diluted L-cysteine
composition. In some further examples, the therapeutically
effective dosing regimen can provide less than or equal to 5
.mu.g/kg/d of Aluminum. In still further examples, the
therapeutically effective dosing regimen can provide less than or
equal to 4 .mu.g/kg/d of Aluminum, or less than or equal to 3
.mu.g/kg/d of Aluminum. In certain embodiments, the methods result
in a daily dosage of Aluminum from the composition of from about 2
.mu.g/kg/d to not more than 5 .mu.g/kg/d.
[0214] The diluted L-cysteine composition for infusion can be
administered for the treatment of a number of conditions. For
example, L-cysteine can be administered to meet the intravenous
amino acid nutritional requirements of individuals (e.g. infants)
receiving total parenteral nutrition. As such, in some examples,
the subject can be a subject in need of total parenteral nutrition
(TPN). In some additional examples, L-cysteine can be administered
for the treatment of osteoarthritis, rheumatoid arthritis, angina,
chronic bronchitis, chronic obstructive pulmonary disease (COPD),
influenza, acute respiratory distress syndrome (ARDS), diabetes
(e.g. type 2 diabetes), the like, or a combination thereof.
[0215] In certain embodiments, the subject matter described herein
is directed to methods of preparing a composition, comprising:
[0216] Stirring Water for Injection, USP (WFI) in a vessel at a
temperature of NMT about 60.degree. C.;
[0217] Contacting the stirring WFI with Argon until the dissolved
oxygen is NMT 1 ppm;
[0218] Allowing the vessel to cool to a temperature of NMT
30.degree. C.;
[0219] Contacting under the Argon the WFI with L-Cysteine
Hydrochloride, Monohydrate, USP (L-Cysteine) for NLT about 15
mins;
[0220] Continuing the mixing under Argon until the dissolved oxygen
is NMT 1 ppm;
[0221] Adjusting the pH to about 1.8 with concentrated Hydrochloric
Acid, NF and/or 5.0 N Sodium Hydroxide, NF;
[0222] Mixing for a minimum of about 10 minutes;
[0223] Capping the vessel under Argon and allowing to stand;
[0224] Filling said mixed liquid into individual single use
containers;
[0225] Reducing head space oxygen to about 5.0% to 0.5% and sealing
said containers
[0226] wherein the dissolved oxygen in the container is about 0.1
ppm to about 5 ppm.
[0227] The subject matter described herein includes, but is not
limited to, the following specific embodiments: [0228] 1. A stable
L-cysteine composition for parenteral administration,
comprising:
[0229] L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof in an amount from about 10 mg/mL to about
100 mg/mL;
[0230] Aluminum (Al) in an amount from about 1.0 parts per billion
(ppb) to about 250 ppb;
[0231] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine;
[0232] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0233] a pharmaceutically acceptable carrier, comprising water;
[0234] headspace O.sub.2 that is from about 0.5% to 4.0% from the
time of manufacture to about 1 month from manufacture when stored
at room temperature;
[0235] dissolved oxygen present in the carrier in an amount from
about 0.1 parts per million (ppm) to about 5 ppm from the time of
manufacture to about 1 month from manufacture when stored at room
temperature,
[0236] wherein the composition is enclosed in a single-use
container having a volume of from about 10 mL to about 100 mL.
[0237] 2. The composition of embodiment 1, wherein the composition
is essentially free of an antioxidant. [0238] 3. The composition of
embodiment 1 or 2, wherein said Aluminum is present in an amount
from about 1.0 ppb to about 200 ppb. [0239] 4. The composition of
embodiment 1, 2 or 3, wherein said Aluminum is present in an amount
from about 1.0 ppb to about 180 ppb. [0240] 5. The composition of
embodiment 1, 2, 3 or 4, wherein said Aluminum is present in an
amount from about 1.0 ppb to about 170 ppb. [0241] 6. The
composition of embodiment 1, 2, 3, or 5, wherein said Aluminum is
present in an amount from about 1.0 ppb to about 160 ppb. [0242] 7.
The composition of embodiment 1, 2, 3, 4, 5 or 6, wherein said
Aluminum is present in an amount from about 1.0 ppb to about 150
ppb. [0243] 8. The composition of embodiment 1, 2, 3, 4, 5, 6 or 7,
wherein said Aluminum is present in an amount from about 1.0 ppb to
about 130 ppb. [0244] 9. The composition of embodiment 1, 2, 3, 4,
5, 6, 7 or 8, wherein said Aluminum is present in an amount from
about 1.0 ppb to about 100 ppb. [0245] 10. The composition of
embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10, wherein said Aluminum
is present in an amount from about 1.0 ppb to about 50 ppb. [0246]
11. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or
11, wherein said Aluminum is present in an amount from about 1.0
ppb to about 20 ppb or from about 1.0 ppb to about 10 ppb. [0247]
12. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or
11, further comprising one or more heavy metals selected from the
group consisting of Lead (in an amount of from about 1 ppb to about
10 ppb), Nickel (in an amount of from about 5 ppb to about 40 ppb),
Arsenic (in an amount of from about 0.1 ppb to about 10 ppb), and
Mercury (in an amount of from about 0.2 ppb to about 5.0 ppb).
[0248] 13. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11 or 12, wherein said heavy metals are present in total in an
amount from about 2.0 ppb to about 8.0 ppb. [0249] 14. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 or
13, further comprising iodide and fluoride, each present in an
amount from about 0.1 ppm to about 20 ppm. [0250] 15. The
composition of embodiment 14, wherein said ions are present in
total an amount from about 2.8 ppm to about 5.8 ppm. [0251] 16. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14 or 15, wherein said dissolved oxygen is present in an amount
from about 0.1 ppm to about 5 ppm. [0252] 17. The composition of
embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 or 16,
wherein said dissolved oxygen is present in an amount from about
0.1 ppm to about 3 ppm. [0253] 18. The composition of embodiment 1,
2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 or 17, wherein
said dissolved oxygen is present in an amount from about 0.10 ppm
to about 2.0 ppm.
[0254] 19. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17 or 18, wherein said dissolved oxygen
is present in an amount from about 0.1 ppm to about 1.0 ppm. [0255]
20. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15, 16, 17, 18 or 19, wherein the composition has
been stored at room temperature. [0256] 21. The composition of
embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19 or 20, wherein the storage is for 1 year or less. [0257]
22. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11, 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21, wherein the storage
is for about 9 months. [0258] 23. The composition of embodiment 1,
2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,
21 or 22, wherein L-cysteine or a pharmaceutically acceptable salt
thereof and/or hydrate thereof is present in the composition in an
amount from about 20 mg/mL to about 70 mg/mL. [0259] 24. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22 or 23, wherein L-cysteine or
a pharmaceutically acceptable salt thereof and/or hydrate thereof
is present in the composition in an amount of about 50 mg/mL.
[0260] 25. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 or 24,
wherein the container is an internally coated glass container.
[0261] 26. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 or 25,
wherein said internally coated glass container is coated with SiO2.
[0262] 27. The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 or
26, essentially free of cystine precipitate. [0263] 28. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 or 27,
wherein said L-cysteine is present in an amount of about 37.5 mg/mL
as free base, or a pharmaceutically acceptable salt thereof and/or
hydrate thereof. [0264] 29. The composition of embodiment 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27 or 28, wherein the Aluminum is present in
the composition in an amount not more than 200 ppb after storage at
ambient temperature for a period of 3 months or less, said Aluminum
comprising, from about 1.0 ppb to about 100 ppb of Aluminum from
the container, from about 1.0 ppb to about 100 ppb of Aluminum from
stopper for the container, from about 1.0 ppb to about 100 ppm of
Aluminum from the L-cysteine, and from aboutl. 0 ppb to about 20
ppb of Aluminum from the water. [0265] 30. The composition of
embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28, wherein the
Aluminum is present in the composition in an amount not more than
200 ppb after storage at ambient temperature for a period of 6
months or less, said Aluminum comprising, from about 0 ppb to about
100 ppb of Aluminum from the container, from about 1.0 ppb to about
100 ppb of Aluminum from stopper for the container, from about 1.0
ppb to about 100 ppm of Aluminum from the L-cysteine, and from
about 0 ppb to about 20 ppb of Aluminum from the water. [0266] 31.
The composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or
28, wherein the Aluminum is present in the composition in an amount
not more than 200 ppb after storage at ambient temperature for a
period of 9 months or less, said Aluminum comprising, from about
1.0 ppb to about 100 ppb of Aluminum from the container, from about
1.0 ppb to about 100 ppb of Aluminum from stopper for the
container, from about 1.0 ppb to about 100 ppm of Aluminum from the
L-cysteine, and from about 1.0 ppb to about 20 ppb of Aluminum from
the water. [0267] 32. The composition of embodiment 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23,
24, 25, 26, 27 or 28, wherein the Aluminum is present in the
composition in an amount not more than 200 ppb after storage at
ambient temperature for a period of 12 months or less, said
Aluminum comprising, from about 1.0 ppb to about 100 ppb of
Aluminum from the container, from about 1.0 ppb to about 100 ppb of
Aluminum from stopper for the container, from about 1.0 ppb to
about 100 ppm of Aluminum from the L-cysteine, and from about 1.0
ppb to about 20 ppb of Aluminum from the water. [0268] 33. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein cystine is present in the composition in an amount not more
than 2 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0269] 34. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein cystine is present in the composition in an amount not more
than 1 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0270] 35. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein cystine is present in the composition in an amount not more
than 0.5 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0271] 36. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein cystine is present in the composition in an amount of about
0.3 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 about months. [0272] 37. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 2 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0273] 38. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 1 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0274] 39. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 0.5 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0275] 40. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 0.3 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0276] 41. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 0.2 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0277] 42. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein pyruvic acid is present in the composition in an amount not
more than 0.1 wt % relative to L-cysteine after storage at ambient
temperature for a period of 9 months or less. [0278] 43. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
further comprising in the vial, headspace oxygen in an amount of
less than 1.0%. [0279] 44. The composition of embodiment 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27 or 28, further comprising in the vial,
headspace oxygen in an amount of less than 0.9%. [0280] 45. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
further comprising in the vial, headspace oxygen in an amount of
less than 0.8%. [0281] 46. The composition of embodiment 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27 or 28, further comprising in the vial,
headspace oxygen in an amount of less than 0.6%. [0282] 47. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
further comprising in the vial, headspace oxygen in an amount of
less than 0.4%. [0283] 48. The composition of embodiment 1, 2, 3,
4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27 or 28, further comprising in the vial,
headspace oxygen in an amount of less than 0.2%. [0284] 49. The
composition of embodiment 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 or 28,
wherein the pH of the composition is about 1.6 to about 2.0. [0285]
50. A stable composition from about 100 mL to about 1000 mL for
administration via a parenteral infusion within about 24 to about
48 hours of admixture, comprising a mixture of a composition of
L-Cysteine of embodiments 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29,
30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46,
47, 48 or 49; and an amino acid composition that is essentially
free of L-Cysteine comprising one or more amino acids selected from
the group consisting of: leucine, isoleucine, lysine, valine,
phenylalanine, histidine, threonine, methionine, tryptophan,
alanine, arginine, glycine, proline, serine, and tyrosine. [0286]
51. The stable composition for infusion of embodiment 50, wherein
the composition of L-Cysteine is the composition of embodiment 1,
12 or 28. [0287] 52. The stable composition for injection of
embodiment 50 or 51, wherein the Aluminum is present in an amount
from about 1.0 parts per billion (ppb) to about 100 ppb. [0288] 53.
The stable composition for injection of embodiment 50, 51 or 52,
wherein the Aluminum is present in an amount from about 1.0 parts
per billion (ppb) to about 50.0 ppb. [0289] 54. The stable
composition for injection of embodiment 50, 51, 52 or 53, wherein
the Aluminum is present in an amount from about 1.0 parts per
billion (ppb) to about 30.0 ppb. [0290] 55. The stable composition
for injection of embodiment 50, 51, 52, 53 or 54, further
comprising a sugar. [0291] 56. The stable composition for injection
of embodiment 50, 51, 52, 53, 54 or 55, wherein the sugar is
dextrose. [0292] 57. A method of reducing Aluminum administration
from a parenteral nutrition regimen comprising L-cysteine,
comprising: [0293] administering to a subject a composition of
embodiment 50, 51, 52, 53, 54, 55 or 56,
[0294] wherein the Aluminum administered to said subject is reduced
compared to administration of a standard parenteral composition
comprising L-cysteine. [0295] 58. The method of embodiment 57,
wherein the Aluminum is reduced by about 5%, or about 10%, or about
15%, or about 20%, or about 25%, or about 30%, or about 35%, or
about 40%, or about 45%, or about 50%, or about 55%, or about 60%,
or about 65%, or about 70%, or about 75%, or about 80%, or about
85%, or about 90%, or about 95%. [0296] 59. A method of reducing
Aluminum administration from a total parenteral nutrition regimen
comprising L-cysteine, the method comprising, mixing a composition
comprising L-cysteine or a pharmaceutically acceptable salt thereof
and/or hydrate thereof comprising:
[0297] Aluminum in an amount from about 10 parts per billion (ppb)
to about 80 ppb;
[0298] L-cystine in an amount from about 0.001 wt % to about 2.0 wt
% relative to L-cysteine; and
[0299] pyruvic acid in an amount from about 0.001 wt % to about 2.0
wt % relative to L-cysteine;
[0300] with a composition comprising one or more amino acids
selected from the group consisting of: leucine, isoleucine, lysine,
valine, phenylalanine, histidine, threonine, methionine,
tryptophan, alanine, arginine, glycine, proline, serine, and
tyrosine; and
[0301] a pharmaceutically acceptable carrier, comprising water,
to form a composition for infusion having a volume of about 100 mL
to about 1000 mL, wherein the Aluminum provided in said parenteral
nutrition regimen is from about 1-2 to about 4-5 micrograms/kg/day.
[0302] 60. A method of treating a subject having an adverse health
condition that is responsive to L-cysteine administration,
comprising:
[0303] diluting a stable L-cysteine composition of embodiments 50,
51, 52, 53, 54, 55 or 56, with an intravenous fluid to prepare a
diluted L-cysteine composition for infusion; and
[0304] infusing the diluted L-cysteine composition for infusion to
a subject to provide a therapeutically effective dose of L-cysteine
or a pharmaceutically acceptable salt thereof and/or hydrate
thereof to the subject in a therapeutically effective dosing
regimen. [0305] 61. The method of embodiment 57, 58, 59, or 61,
wherein said administering is from 30 minutes to about 24-48 hrs.
[0306] 62. The method of embodiment 61, wherein the amount of
Aluminum in the composition results in a daily dosage of Aluminum
from about 1 mcg/kg/day to about 4 mcg/kg/day, or about 2
mcg/kg/day to about 4 mcg/kg/day, or about 1 mcg/kg/day to about 5
mcg/kg/day, or about 2 mcg/kg/day to about 5 mcg/kg/day. [0307] 63.
The method of embodiment 61 or 62, wherein the intravenous fluid is
a member selected from the group consisting of: isotonic saline,
glucose solution, glucose saline, dextrose solution, crystalline
amino acid solution, and combinations thereof. [0308] 64. The
method of embodiment 61, 62 or 63, wherein administering is
performed via intravenous infusion. [0309] 65. The method of
embodiment 61, 62, 63, or 64, wherein L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof is
administered at a rate of from about 1 mL/min to about 10 ml/min.
[0310] 66. The method of embodiment 61, 62, 63, 64 or 65, wherein
the therapeutically effective dose of L-cysteine or a
pharmaceutically acceptable salt thereof and/or hydrate thereof is
an amount from about 50 mg to about 1200 mg. [0311] 67. The method
of embodiment 61, 62, 63, 64, 65 or 66, wherein the therapeutically
effective dose of L-cysteine or a pharmaceutically acceptable salt
thereof and/or hydrate thereof is an amount of about 100-500 mg.
[0312] 68. The method of embodiment 61, 62, 63, 64, 65, 66 or 67,
wherein the L-cysteine is L-cysteine hydrochloride monohydrate.
[0313] 69. The method of embodiment 61, 62, 63, 64, 65, 66, 67 or
68, wherein the subject is a subject in need of total parenteral
nutrition (TPN). [0314] 70. The method of embodiment 61, 62, 63,
64, 65, 66, 67, 68 or 69, wherein the subject is an infant having
an age of 6 months or less. [0315] 71. The method of embodiment 61,
62, 63, 64, 65, 66, 67, 68, 69, 70 or 71, wherein the
therapeutically effective dosing regimen is a total parenteral
nutrition (TPN) dosing regimen. [0316] 72. A method of preparing
the composition of any above embodiment, comprising stirring Water
for Injection, USP (WFI) in a vessel at a temperature of NMT about
60.degree. C.;
[0317] Contacting the stirring WFI with Argon until the dissolved
oxygen is NMT 1 ppm;
[0318] Allowing the vessel to cool to a temperature of NMT
30.degree. C.;
[0319] Contacting under the Argon the WFI with L-Cysteine
Hydrochloride, Monohydrate, USP (L-Cysteine) for NTL about 15
mins;
[0320] Continuing the mixing under Argon until the dissolved oxygen
is NMT 1 ppm;
[0321] Adjusting the pH to about 1.8 with concentrated Hydrochloric
Acid, NF and/or 5.0 N Sodium Hydroxide, NF;
[0322] Mixing for a minimum of about 10 minutes;
[0323] Capping the vessel under Argon and allowing to stand;
and
[0324] Performing Head Space oxygen Reduction after filling,
wherein the dissolved oxygen is about 0.1 ppm to about 5 ppm.
[0325] With this in mind, the following examples are intended to
illustrate, but not limit, various aspects of the compositions and
methods described herein.
EXAMPLES
Example 1
Compounding L-Cysteine Hydrochloride Injection, USP, 50 mg/mL, 10
mL Vial
[0326] Compounding was initiated with the addition of 40.+-.1.0 kg
of Water for Injection, USP (WFI) was added to the Xcellerex Mixing
System via an addition funnel. A target water temperature of NMT
60.degree. C. was maintained throughout WFI addition using a heat
exchanger. With continuous mixing at a speed of 126 rpm, Argon
overlaying of the WFI began in the mixing bag and continued until
the dissolved oxygen was NMT 1 ppm; then the mixing bag was allowed
to cool to a temperature of NMT 30.degree. C.
[0327] With continuous mixing and Argon overlaying, the L-Cysteine
Hydrochloride, Monohydrate, USP (L-Cysteine) was added directly
into the vortex of the mixing bag. The mixing continued for NLT 15
minutes or until complete dissolution was observed. The dissolved
oxygen content was measured and recorded prior to the addition of
L-Cysteine, immediately following the addition of L-Cysteine, and
following the NLT 15-minute mixing period. With continuous mixing
and Argon overlaying, the temperature, pH and dissolved oxygen of
the solution was measured and recorded. Argon overlaying continues
until the dissolved oxygen was NMT 1 ppm.
[0328] With continuous mixing and Argon overlaying, the solution's
pH was adjusted to a target of 1.8 with concentrated Hydrochloric
Acid, NF and/or 5.0 N Sodium Hydroxide, NF. Following pH
adjustment, the solution was allowed to mix for a minimum of 10
minutes, and then the pH was verified and adjusted as needed with
the Hydrochloric Acid, NF and/or N Sodium Hydroxide, NF. Then, the
solution's weight, adjusted pH and dissolved oxygen was measured
and recorded.
[0329] With continuous mixing and Argon overlaying, the solution
was q.s.'d with the WFI to a final weight of 50.6 kg and allowed to
mix for approximately 10 minutes. The final solution weight,
solution temperature, solution pH, and dissolved oxygen was then
measured and recorded. Following these steps, the mixing bag was
fully inflated with Argon and capped, and the solution was
transferred from the mixing bag to the solution holding bag.
Example 2
L-Cysteine Injection in High Quality Glass Vials
[0330] L-Cysteine injection was compounded as per Example 1. The
bulk solution was filled then using high quality glass vials (10
mL) from Schott. These vials are known as Schott Type 1 USP glass.
The glass was a standard glass of pharmaceutical quality but was
uncoated. The product was put on stability and was monitored for
impurities, particulates, and Aluminum. The product was quite
stable for all the time points tested up to 12 months. There were
no unacceptable particulate counts.
[0331] However, as the data show, the product resulted in an
unacceptably high aluminum content. The data for aluminum levels
are shown below.
TABLE-US-00006 TABLE 6 Aluminum Levels 6 Months Lot # Release
25.degree. C./60% RH 40.degree. C./75% RH XMHH1609 212 ppb 569 ppb
1.306 ppb XMHH1610 199 ppb 748 ppb 1,374 ppb XMHH1611 230 ppb 726
ppb 1,044 ppb
Example 3
L-Cysteine Injection in Plastic Vials
[0332] L-Cysteine injection was compounded as per Example 1. The
bulk solution was filled then using plastic vials obtained from
Medicopak, Inc. These vials are made of cyclic olefin copolymer
(COC). The product was put on stability and was monitored for
impurities, particulates, and Aluminum. The product was not stable
beyond 1 month at accelerated storage conditions and failed at room
temperature conditions by the third month data point.
TABLE-US-00007 TABLE 7 Particulate levels 1 Month/ 3 Month/ Lot
Number/Vial Release 40.degree. C./75% RH* 25.degree. C./60% RH*
XMHG1700/10 mL Passing Failed Visual, Failed Visual, COC vial
particulates particulates XMHG1701/10 mL Passing Failed Visual,
Failed Visual, COC vial particulates particulates XMHG1702/10 mL
Passing Failed Visual, Failed Visual, COC vial particulates
particulates
However, the product showed acceptable aluminum content. The data
for aluminum levels are shown below.
TABLE-US-00008 TABLE 8 Aluminum Levels Time Point Lot XMHG 1700 Lot
XMHG 1701 Lot XMHG 1702 Time Zero 1 ppb 2 ppb 1 ppb
Aluminum at additional time points was not measured because the
product was abandoned due to unacceptably high particulate
count.
Example 4
Headspace Reduction and Argon Overlay
[0333] Data from Example 3 show that plastic vials do not provide
the desired purity and stability of a L-cysteine composition for
injection. This study was to evaluate the parameters to determine
headspace oxygen reduction conditions. The product was manufactured
as per Example 1. The drug product was overlaid with Argon until
the dissolved oxygen levels were no more than (NMT) 1 part per
million (PPM). Vials were filled and placed in the VirTis Benchmark
Lyophilizer, OP4159, for Head Space reduction. In addition, empty
vials were also placed into the lyo for Head Space reduction as
part of the study.
[0334] Multiple points were monitored during the manufacturing
process as part of the study including the following: 1)
Compounding; 2) Pre-Filling; 3) Filling; 4) Post Filling; and 5)
Head Space Reduction (HSR). The monitoring involved taking
dissolved oxygen (DO) measurements on drug product for filled vials
throughout the manufacturing process and performing Head Space Gas
Analysis on drug product for both filled and empty vials post head
space reduction. Additionally, fill hold samples representing the
maximum exposure during the filling step were analyzed for the
dissolved oxygen and Head Space Oxygen Analysis.
[0335] The sampling and testing that was performed per the study is
shown in Table 9. Samples were collected throughout the
manufacturing process to determine the impact of critical process
parameters on its predetermined critical quality attribute.
TABLE-US-00009 TABLE 9 Sampling and Testing Methodology Sample
Testing Acceptance Operation Location/Quantity Requirements
Criteria Compounding The bulk solution was mixed under Dissolved
Dissolved Argon overlaying. Measure and record Oxygen Oxygen <1
final solution weight, solution ppm temperature, solution pH, and
dissolved oxygen. Measure and record the final dissolved oxygen.
Filling For Load A [Trays 1-4, 17-20] use Dissolved Dissolved
forceps to remove four (4) filled vials Oxygen Oxygen = from each
tray as it is filled Fully seat Report Value the stoppers of the
removed filled vials immediately after removal and then label vials
appropriately Filling As Tray 1 is loaded into the Lyo, using
Dissolved Dissolved Hold forceps, carefully remove 20 vials from
Oxygen Oxygen = the appropriate locations. Do not fully Report
Value stopper the vials. Mark the vials "Fill Hold" Similarly,
after Tray 21 has been completely filled and is being placed into
the cart, use forceps to remove twenty (20) filled vials from the
appropriate As Tray 21 is being loaded into the Lyophilizer for
Head Space Reduction, use forceps to remove two (2) of the vials
marked "Fill Hold", fully seat the stoppers of the vials, and label
appropriately. Lyo Loading For Trays 1-4, 17-20, 21-24, and
Dissolved Dissolved 37-40, use forceps to remove two (2) Oxygen
Oxygen = filled vials, as each tray is loaded into Report Value the
Lyo, fully seat the stoppers of the vials, and label appropriately
Capping Following headspace reduction and Dissolved Dissolved
immediately prior to loading each tray Oxygen Oxygen = into the RAB
for capping, use forceps to Report Value remove four (4) filled
vials from each Head Space Head Space Gas tray. Place a mark on
each of the Gas Analysis Analysis = removed vials for
identification Report Value purposes and place the marked vials
back into the tray. Load the tray into the RAB for capping.
Following the capping of each tray, remove the marked vials from
the tray and label appropriately. Capping Following headspace
reduction and Dissolved Dissolved Fill Hold capping, remove the
eighteen (18) vials Oxygen Oxygen = marked "Fill Hold" from Tray 21
for Report Value testing. Head Space Head Space Gas Gas Analysis
Analysis = Report Value
[0336] The data collected are as follows: Dissolved oxygen;
Comparison of dissolved oxygen levels per tray at various stages of
the manufacturing process; Filled vials head space oxygen; Held
vials dissolved oxygen (ppm) and head space oxygen content (%);
Comparison of Post Head Space Dissolved Oxygen (ppm) and Head Space
Oxygen Content (%).
[0337] Dissolved oxygen data at various stages of the manufacturing
process are shown in Table 10. A two (2) hour delay in the DO
testing for the Post Filling-Pre HSR samples (Tray 1-4; tested
using gas calibration) exhibited an average value of 11.77 ppm, an
increase of 6.65 ppm from the average of 5.12 ppm measured live
time after filling using the liquid calibration. Furthermore, the
samples tested live time but using the gas calibration (Tray 17-20)
exhibited an average value of 6.41 ppm, an increase of 1.29 ppm
from the average of 5.12 ppm measured after filling using the
liquid calibration. Starting Tray 21 of the Post Filling-Pre HSR
step, the calibration was corrected to a liquid calibration.
Comparison of dissolved oxygen levels at various stages of the
manufacturing process is provided in FIGS. 1 and 2.
TABLE-US-00010 TABLE 10 Dissolved Oxygen Levels. Post Filling -
Post Filling - Post HSR - Pre HSR During Loading Capping - Filled
Tray Number (ppm) of Lyo (ppm) Vials (ppm) 1 11.932 10.179 0.480 2
11.228 9.925 0.470 3 11.486 10.577 0.508 4 12.441 10.370 0.409 17
6.808 9.893 0.525 18 6.628 9.859 0.707 19 5.860 9.854 0.486 20
6.343 9.720 0.495 21 5.641 10.329 0.735 22 5.374 10.308 0.546 23
5.190 10.149 0.481 24 7.073 9.844 0.541 37 4.328 9.544 0.403 38
3.604 9.251 0.378 39 4.559 9.265 0.390 40 5.173 9.577 0.369 Average
5.117 9.915 0.495 STD 1.03 0.39 0.11 % RSD 20.1 3.9 21.3
TABLE-US-00011 TABLE 11 Filled Vials Head Space Oxygen. Post HSR
-Capping - Post Capping - Filled Vials Empty Vials Tray Number (%
Oxygen) (% Oxygen) 1 1.147 0.981 2 1.399 1.116 3 1.551 0.980 4
0.950 1.139 17 1.382 1.156 18 1.766 1.236 19 1.154 1.224 20 1.265
1.180 21 1.844 1.221 22 1.365 1.169 23 0.890 1.295 24 1.148 1.114
37 0.880 1.300 38 0.871 1.151 39 0.850 1.097 40 0.889 1.042 Average
1.209 1.150 STD 0.32 0.10 % RSD 26.7 8.3
TABLE-US-00012 TABLE 12 Held vials dissolved oxygen (ppm) and head
space oxygen content (%). Dissolved Dissolved Head Space Oxygen
Post Oxygen Post Oxygen % Post Held Vials- Filling - HSR - Capping
- HSR- Capping - Tray 1/ Loading of Lyo Filled Vials Filled Vials
Tray 21 (ppm) (ppm) (%) Sample 1 10.685 0.578 1.563 Sample 2 10.467
0.588 1.390 Sample 3 -- 0.565 1.522 Sample 4 -- 0.550 1.447 Average
10.576 0.570 1.481 STD 0.15 0.02 0.08 % RSD 1.5 2.9 5.2
TABLE-US-00013 TABLE 13 Comparison of Post Head Space Dissolved
Oxygen (ppm) and Head Space Oxygen Content (%). Dissolved Dissolved
Head Space Oxygen Pre Oxygen Post Oxygen % Post HSR (ppm) HSR -
(ppm) HSR (%) PROT-000055 Study -- -- 1.150 Empty Vials Avg.
PROT-000055 Study 9.915 0.495 1.209 Filled Vials Avg. 2018-RD-022
Study -- -- 0.49 Empty Vials Avg. 2018-RD-022 Study 7.14 2.55 1.27
Filled Vials Avg. Lot XMHJ1705 -- 0.637 2.28 Lot XMHJ1706 -- 0.391
1.92 Lot XMHJ1707 -- 1.585 1.94
[0338] The results from these experiments demonstrate the
effectiveness of the Head Space Reduction (HSR) cycle in attaining
reduced and consistent dissolved oxygen (DO) levels in the finished
drug product. The results showed a trend with an increase in
dissolved oxygen level from 0.36 parts per million (ppm) recorded
during compounding, to an average of 5.12 ppm measured after
filling, a further increase to an average of 9.92 ppm while loading
the Lyophilizer, and finally a reduction of dissolved oxygen to an
average of 0.50 ppm after headspace reduction. The overall trends
are displayed in FIGS. 1 and 2. The plots and data also show that
the average increase in dissolved oxygen levels from compounding to
the filled vials was 4.76 ppm. Also, as the vials were stored in
the transfer cart, an average dissolved oxygen increase of about
4.80 ppm was observed prior to being loaded in the Lyophilizer for
head space reduction. The total average increase in dissolved
oxygen levels from compounding to vials being loaded in the
lyophilizer was 9.56 ppm. The average decrease in dissolved oxygen
observed in vials post head space reduction was 9.42 ppm. In
addition, the oxygen levels obtained across all trays analyzed pre
and post HSR were consistent throughout the manufacturing
process.
[0339] Head Space Gas Analysis was performed on both filled and
empty vials taken from designated locations in selected trays.
Percent (%) Oxygen results achieved across the trays showed a
relatively uniform head space reduction process throughout the
chamber. The average % Oxygen for the empty vials was found to be
1.15%, compared with 1.21% for the filled vials (Reference Table
11).
[0340] Dissolved Oxygen and Head Space Gas Analysis were also
performed on the Held Vials from designated locations in Tray 1 as
part of the stressed sample analysis over the course of the
manufacturing process. The results showed a comparable trend to
that observed for the regular samples across the study (Reference
Table 12). Specifically, an increase in dissolved oxygen level from
0.36 ppm recorded during compounding, to 5.64 ppm measured after
filling, a further increase to an average of 10.58 ppm while
loading the Lyophilizer, and finally a reduction of dissolved
oxygen to an average of 0.57 ppm after headspace reduction. The
average % Oxygen for the filled held vials was found to be 1.48%,
compared with 1.21% for the filled regular vials. This indicated
that the HSR cycle was effective in achieving comparable DO and
Headspace oxygen results irrespective of the maximum fill time
exposure (approximately 7 hours; represented by the Fill Hold
Vials) and has no impact on the quality of the product. The use of
the Lyophilizer, in the Head Space Reduction of L-Cysteine
Hydrochloride Injection, USP (50 mg/mL) has been shown to be
effective for the control of reduced and consistent oxygen levels,
and is suitable for scale up for the existing process and equipment
as the product meets all the critical quality attributes.
Example 5
[0341] Head space oxygen reduction was accomplished using an
automated filling equipment that can handle high speed filling, in
contrast to slow or low volume operation such as through a
lyophilizer as described in Examples 1 and 4. The high-speed filler
is capable of using vacuum and gas overlay in alternate pulses to
reduce the head space oxygen. Each pulse is timed to be within 0.1
to 5 seconds such that typically 3-5 pulses are conducted in one
head space oxygen reduction cycle. The pulse rate can be adjusted
after multiple trials to provide optimal headspace reduction with
optimal speed of the filler such that no product is lost through
back suction or through spillage and average speeds of from about
20 vials/minute to about 200 vials per minute, depending on the
number of fill heads used.
[0342] A 50 L batch was prepared utilizing the current compounding
procedure described above in Example 1. The filler was set up to
fill and reduce head space oxygen as per the process shown in FIG.
3.
[0343] The total head space reduction cycle lasted about 25 seconds
per operation. The vials were analyzed for head space oxygen at
time zero and at 1-month time point. The data are shown below.
[0344] The evaluation of the filler's performance demonstrated that
the headspace oxygen control was comparable to or better than the
current process for L-Cysteine. Headspace oxygen values obtained
ranged from 0.2% to 0.5% for all vials filled, including empty
vials during start up. Vials tested after 1-month storage at
ambient conditions also maintain headspace oxygen levels between
0.4 and 1.5%. The Tables below show a summary of the results for
the in process and 1-month stability testing. Also included below
is a comparison of the in-process data obtained from previously
manufactured lots of L-Cysteine utilizing the lyophilizer headspace
reduction method. The data show the headspace oxygen values at Time
Zero are lower with the high-speed filler than the lyophilizer
process.
TABLE-US-00014 TABLE 14 Headspace Oxygen Levels at Time Zero for
High-Speed Filler PROT-000213 - Time Zero Overall Overall Tray 5
Tray 10 Low High Average Headspace O.sub.2 (%) 0.473 0.378 0.243
0.490 0.372
TABLE-US-00015 TABLE 15 Headspace Oxygen Levels at 1 Month for
High-Speed Filler PROT-000213 - 1 Month Tray No. 5 Tray No. 10 Low
High Average Low High Average Headspace O.sub.2 (%) 0.412 1.518
0.995 0.98 1.454 1.262
TABLE-US-00016 TABLE 16 Comparison of Headspace Oxygen Levels
between Lyophilizer and High-Speed Filler Operations XMHJ1705
XMHJ1706 XMHJ1707 PROT-000213 Batch (Current (Current (Current
(High Speed (Process) Process) Process) Process) Filler) Average
2.3% Oxygen 1.9% Oxygen 1.9% Oxygen 0.4% Oxygen Low N/A N/A N/A
0.2% Oxygen High N/A N/A N/A 0.5% Oxygen 1 Month Room 0.9% Oxygen
2.8% Oxygen 1.2% Oxygen 1.1% Oxygen Temperature (0.4% to 1.5%)
N/A--Not Applicable
[0345] FIG. 4 shows the comparison of oxygen headspace control
between the lyophilizer chamber headspace control method versus the
high-speed filler vacuum stoppering system. The lyophilizer chamber
for headspace reduction was utilized for lots XMHJ1705, XMHJ1706,
and XMHJ1707 of L-Cysteine Hydrochloride injection. The time zero
oxygen headspace results for the engineering batch PROT-000213 are
shown in comparison to the previously manufactured lots. Results
shown were measured at the time of manufacturing on samples of
vials from the batches. Oxygen percentage was taken for the samples
from PROT-000213 using the NeoFox Phase Fluorometer. Lots XMHJ1705,
XMHJ1706, and XMHJ1707 used Argon Headspace Analysis,
QCTM-000014.
[0346] In addition to the head space oxygen levels, dissolved
oxygen levels were also measured. Data are shown in FIG. 5.
[0347] The dissolved oxygen levels and head space oxygen levels
were measured again at 1 month stability time point at room
temperature conditions:
TABLE-US-00017 TABLE 17 Headspace and Dissolved Oxygen Data
Comparison at 1 month Study - 1 Month Tray No. 5 Tray No. 10 Sample
1 Sample 2 Sample 3 Sample 4 Sample 1 Sample 2 Sample 3 Headspace
O.sub.2 0.576 0.412 1.518 1.475 0.98 1.454 1.352 (%) Dissolved
O.sub.2 0.545 0.706 2.328 2.042 2.173 2.372 2.149 (ppm)
Example 6
Purity Profile and Long-Term Stability of L-Cysteine Composition
for Injection
[0348] An L-cysteine composition for injection was manufactured as
described in Example 1. The glass used was Schott Type 1 USP Plus
glass, internally coated with silicon dioxide. The composition was
subjected to stability testing to evaluate the stability of the
composition over time. Table 18 shows various stability data
collected for the L-cysteine composition for injection over a
9-month testing period. Samples of exhibit batches stored upright
at room temperature for 9 months at 25.degree. C./60% RH. Note: two
samples were tested for dissolved oxygen and head-space oxygen.
TABLE-US-00018 TABLE 18 Characterization of L-Cysteine Composition
for Injection Test XMHJ1705 XMHJ1706 XMHJ1707 L-Cysteine HCl Up Up
Up 100.4% 101.3% 101.2% Related Compounds: L-Cystine 0.3% 0.3% 0.3%
Pyruvic Acid Total 0.1% 0.2% 0.1% Specified RRT-1.98 0.2% 0.2% 0.2%
Individual ND ND ND Unspecified 0.5% 0.7% 0.6% Total Impurities
Dissolved Oxygen (1) 0.12 ppm (1) 0.13 ppm (1) 0.14 ppm (2) 0.13
ppm (2) 0.14 ppm (2) 0.13 ppm Head-Space Oxygen (1) 0.16% (1) 0.53%
(1) 0.56% (2) 0.37% (2) 0.89% (2) 0.50% Aluminum Content 3.2 ppb
2.9 ppb 5.6 ppb Description Clear colorless Clear colorless Clear
colorless solution solution solution
Example 7
Effect of Dissolved Oxygen and Headspace Oxygen on L-cysteine and
Cystine Levels
[0349] An L-cysteine composition for injection was manufactured as
described in Example 1. However, samples of exhibit batches were
tested without head-space reduction and argon overlay during
compounding, then filled, stoppered and capped. Samples were tested
within one week of manufacturing date. Data in Table 19 show the
marked effects of lack of headspace and dissolved oxygen on
component levels within one week. L-Cystine increased by about
0.4%-0.7% within a week for samples with higher dissolved oxygen
and head-space oxygen.
TABLE-US-00019 TABLE 19 Effect of lack of Headspace and Dissolved
Oxygen Control on Product Purity Prior to Prior to Prior to Ave
Values Head-Space Head-Space Head-Space for after Reduction
Reduction Reduction completed Test Tray 1 Tray 19 Tray 23 Batch
L-Cysteine HCl 99.9% 100.1% 100.0% 102.0% L-Cystine 0.8% 0.5% 0.6%
0.1% Head-Space 20.8% 20.3% 20.3% 1.2% Oxygen Dissolved 8.3 ppm 8.6
ppm 8.6 ppm 0.50 ppm Oxygen
Example 8
Evaluation of Anions in L-Cysteine Product
[0350] Inorganic anionic leachables were determined using validated
potentiometric methods utilizing ion selective electrodes. Fluoride
and Iodide were evaluated for this drug product. The leachables
testing results are listed in Tables 20 and 21 below.
TABLE-US-00020 TABLE 20 Leachable Iodide Results for L-Cysteine HCl
Injection [I.sup.-] (ppb) 25.degree. C./60% RH 40.degree. C./75% RH
Replicate Upright Horizontal Inverted Upright Horizontal Inverted
XMHJ1705 1 28.1 27.4 27.1 25.2 24.9 24.7 2 25.9 26.3 25.9 24.0 24.1
24.1 3 28.1 25.3 25.3 24.0 22.3 21.6 Average 27.4 26.3 26.1 24.4
23.7 23.5 SD 1.3 1.0 0.9 0.7 1.3 1.6 % RSD 4.7 3.9 3.6 2.7 5.6 7.0
XMHJ1706 1 81.7 80.3 82.8 80.3 82.0 81.8 2 83.1 81.7 81.5 82.5 82.3
81.3 3 81.7 81.7 81.8 78.1 81.9 82.8 Average 82.2 81.2 82.0 80.3
82.1 82.0 SD 0.8 0.8 0.7 2.2 0.2 0.7 % RSD 0.9 1.0 0.9 2.7 0.2 0.9
XMHJ1707 1 53.5 52.3 53.1 51.7 51.4 50.8 2 52.5 54.0 53.7 51.8 52.0
53.5 3 54.4 52.8 52.8 53.8 53.6 52.6 Average 53.5 53.0 53.2 52.4
52.3 52.3 SD 1.0 0.9 0.4 1.2 1.1 1.4 % RSD 1.8 1.7 0.8 2.2 2.1
2.6
TABLE-US-00021 TABLE 21 Leachable Iodide Results for L-Cysteine HCl
Injection [I.sup.-] (ppb) XMHL1702A XMHL1702B 25.degree. C./
40.degree. C./ 25.degree. C./ 40.degree. C./ 60% RH 75% RH 60% RH
75% RH 6 month 6 month 6 month 6 month Iodide (ppb) 29 24 24 19
[0351] The leachable results for Fluoride indicate levels below 20
ppb and no observable trend in leachable amount over time or
temperature dependence. The leachable results for Iodide indicate
that levels were observed ranging from .about.20-80 ppb. No
noticeable trend in leachable amount including vial orientation or
temperature dependence was observed.
Example 9
Elemental Leachables
[0352] Elemental leachables were evaluated using a validated
inductively coupled plasma mass spectrometric (ICP-MS) method.
ICP-MS method is described in detail in USP and other literature in
the art. The results for the elemental leachables analysis are
summarized in the Table below. The Table lists the Allowable
Elemental Concentrations (AEC) for each identified element.
TABLE-US-00022 TABLE 22 Elemental Impurity Leachables Results for
L-Cysteine HCl Injection [X] (ppb) XMHJ1705 XMHJ1705 25.degree.
C./60% RH 40.degree. C./75% RH AEC Time point (months) Element
(ppb) 1 3 6 9 1 3 6 Molybdenum 14537 <0.5 2 1.75 0.6 <0.5 2
0.91 Zinc 12598 14 2 13.84 23.4 11 38 <QL Iron 12598 25 21 50.52
19 16 60 5.73 Chromium 10660 2 <QL <QL 3.2 2 6 <QL Barium
6784 2 <QL <QL <QL <0.5 2 <QL Tin 5815 1 2 3.38 1.2
3 0.88 Copper 2907 <0.5 <QL <QL 15.0 <0.5 2 <QL
Manganese 2423 1 <QL <QL 0.3 <0.5 2 <QL Lithium 2423
<0.5 5 3.90 0.1 <0.5 6 3.79 Gold 969 5 3 9.76 0.3 3 4 1.76
Antimony 872 1 1 0.88 0.1 1 2 0.60 Selenium 775 <0.5 <QL
<QL 0.1 <0.5 2 <QL Nickel 194 11 9 16.66 8.1 11 9 0.99
Arsenic 174 1 <QL <QL 0.2 1 2 <QL Aluminum 120 <QL
<QL <QL <QL <QL <QL <QL Vanadium 97 <QL <QL
<QL <QL <0.5 4 <QL Silver 97 <0.5 <QL <QL
<QL <QL 17 <QL Ruthenium 97 <0.5 1 0.72 <QL <0.5
2 0.74 Rhodium 97 <0.5 4 4.31 <QL <0.5 8 4.29 Platinum 97
<0.5 <0.5 <QL <QL <0.5 1 <QL Palladium 97 <0.5
<QL <QL <QL <0.5 1 <QL Osmium 97 <0.5 <QL
<QL <QL <0.5 1 <QL Iridium 97 <0.5 6 5.98 <QL
<0.5 7 5.92 Thallium 78 <0.5 4 3.59 <QL <0.5 5 3.59
Cobalt 48 <0.5 <QL <QL 0.1 <0.5 <0.5 <QL Lead 48
2 5 6.77 1.5 2 6 3.33 Mercury 29 <0.5 1 0.78 2 <0.5 1 1.10
Cadmium 19 <0.5 1 1.31 <QL <0.5 2 1.30 XMHJ1705 25.degree.
C./60% RH Time point (months) AEC 12 12 12 Element (ppb) INV HOR UP
Molybdenum 14537 0.4 0.4 0.5 Zinc 12598 7 5 3 Iron 12598 9 157 637
Chromium 10660 1 2 3 Barium 6784 0.4 0.4 0.4 Tin 5815 1 1 1 Copper
2907 0.5 0.8 0.6 Manganese 2423 <QL 2 8 Lithium 2423 0.04 0.05
0.05 Gold 969 0.4 <QL 1 Antimony 872 0.4 0.3 0.3 Selenium 775
<QL 1 <QL Nickel 194 14 14 15 Arsenic 174 0.3 0.3 0.2
Aluminum 120 (4) <QL (19) <QL (5) <QL Vanadium 97 <QL
<QL <QL Silver 97 <QL <QL <QL Ruthenium 97 <QL
<QL <QL Rhodium 97 0.01 0.01 0.01 Platinum 97 <QL <QL
<QL Palladium 97 0.06 0.06 0.1 Osmium 97 <QL <QL <QL
Iridium 97 0.04 0.03 0.04 Thallium 78 <QL <QL <QL Cobalt
48 <QL <QL <QL Lead 48 2 2 2 Mercury 29 0.7 0.7 0.6
Cadmium 19 <QL <QL <QL XMHJ1706 XMHJ1706 25.degree. C./60%
RH 40.degree. C./75% RH AEC Time point (months) Element (ppb) 1 3 6
9 1 3 6 Molybdenum 14537 <0.5 1 1.32 0.4 <0.5 2 1.33 Zinc
12598 10 8 8.23 23.9 10 36 4.25 Iron 12598 9 30 34.02 7.9 10 41
45.60 Chromium 10660 1 <QL <QL 1.9 2 5 <QL Barium 6784
<0.5 <QL <QL <QL 1 1 <QL Tin 5815 1 2 2.91 1.3 1 3
2.08 Copper 2907 <QL <QL <QL <QL <QL 1 <QL
Manganese 2423 <0.5 <QL <QL 0.3 <0.5 1 <QL Lithium
2423 <0.5 4 3.84 0.1 <0.5 6 3.87 Gold 969 2 3 4.38 0.2 2 4
3.99 Antimony 872 1 1 0.81 <QL 1 2 0.91 Selenium 775 <0.5
<QL <QL 0.6 1 3 <QL Nickel 194 11 10 8.66 8.1 11 9 8.68
Arsenic 174 <0.5 <QL <QL 0.4 <0.5 2 <QL Aluminum 120
<QL <QL (2) <QL <QL <QL <QL <QL Vanadium 97
<QL <QL <QL <QL <0.5 4 <QL Silver 97 <QL
<QL <QL <QL <QL 17 <QL Ruthenium 97 <0.5 1 0.73
<QL <0.5 2 0.73 Rhodium 97 <0.5 4 4.29 <QL <0.5 8
4.28 Platinum 97 <0.5 <0.5 <QL <QL <0.5 1 <QL
Palladium 97 <0.5 <QL <QL <QL <0.5 1 <QL Osmium
97 <0.5 <QL <QL <QL <0.5 1 <QL Iridium 97 <0.5
6 5.94 <QL <0.5 7 5.94 Thallium 78 <0.5 4 3.59 <QL
<0.5 5 3.59 Cobalt 48 <0.5 <0.5 <QL <QL <0.5
<0.5 <QL Lead 48 2 6 5.53 2.0 2 6 5.53 Mercury 29 <0.5 1
1.11 1.5 <0.5 1 1.01 Cadmium 19 <0.5 1 1.30 <QL <0.5 2
1.30 XMHJ1706 25.degree. C./60% RH Time point (months) AEC 12 12 12
Element (ppb) INV HOR UP Molybdenum 14537 0.4 0.4 0.4 Zinc 12598 3
6 8 Iron 12598 11 55 10 Chromium 10660 1 1 1 Barium 6784 0.4 0.6
0.4 Tin 5815 1 2 2 Copper 2907 1 0.2 <QL Manganese 2423 0.1 0.6
0.2 Lithium 2423 0.03 0.03 0.04 Gold 969 0.2 0.2 0.3 Antimony 872
0.6 0.5 0.5 Selenium 775 0.4 <QL 0.4 Nickel 194 14 14 14 Arsenic
174 0.8 0.5 0.4 Aluminum 120 (5) <QL (6) <QL (1) <QL
Vanadium 97 <QL <QL <QL Silver 97 <QL <QL <QL
Ruthenium 97 0.005 <QL 0.003 Rhodium 97 0.007 0.005 0.008
Platinum 97 <QL <QL <QL Palladium 97 0.04 0.02 0.03 Osmium
97 <QL <QL <QL Iridium 97 0.03 0.03 0.03 Thallium 78
<QL <QL <QL Cobalt 48 <QL <QL <QL Lead 48 2 2 2
Mercury 29 0.7 0.7 0.7 Cadmium 19 <QL 0.004 <QL XMHJ1707
XMHJ1707 25.degree. C./60% RH 40.degree. C./75% RH AEC Time point
(months) Element (ppb) 1 3 6 9 1 3 6 Molybdenum 14537 <0.5 1
1.22 0.4 <0.5 2 1.21 Zinc 12598 10 4 4.28 22.7 11 38 3.91 Iron
12598 8 26 12.55 8.3 9 74 17.68 Chromium 10660 1 <QL <QL 2.2
1 6 <QL Barium 6784 <0.5 <0.5 <QL <QL <0.5 1
<QL Tin 5815 1 2 2.13 3.2 1 3 2.22 Copper 2907 <0.5 <QL
<QL <QL <0.5 2 <QL Manganese 2423 <0.5 <QL <QL
0.1 <0.5 1 <QL Lithium 2423 <0.5 3.86 3.86 0.2 <0.5 6
3.88 Gold 969 3 3 3.98 0.1 2 4 3.48 Antimony 872 1 1 1.01 <QL 1
2 1.06 Selenium 775 <0.5 <QL <QL 0.1 <0.5 2 <QL
Nickel 194 11 8 7.71 7.4 10 8 7.82 Arsenic 174 1 <QL <QL 0.4
1 2 <QL Aluminum 120 <QL <QL <QL <QL <QL <QL
<QL Vanadium 97 <QL <QL <QL <QL <0.5 4 <QL
Silver 97 <0.5 <QL <QL <QL <QL 17 <QL Ruthenium
97 <0.5 1 0.73 <QL <0.5 2 0.73 Rhodium 97 <0.5 4 4.29
<QL <0.5 8 4.28 Platinum 97 <0.5 <0.5 <QL <QL
<0.5 1 <QL Palladium 97 <0.5 <QL <QL <QL <0.5
1 <QL Osmium 97 <0.5 <QL <QL <QL <0.5 1 <QL
Iridium 97 <0.5 6 5.95 <QL <0.5 7 5.94 Thallium 78 <0.5
4 3.59 <QL <0.5 5 3.56 Cobalt 48 <0.5 <0.5 <QL
<QL <0.5 <0.5 <QL Lead 48 2 6 5.51 1.9 2 6 5.55 Mercury
29 <0.5 1 0.98 1.2 <0.5 1 0.89 Cadmium 19 <0.5 1.30 1.29
<QL <0.5 2 1.29 XMHJ1707 25.degree. C./60% RH Time point
(months) AEC 12 12 12 Element (ppb) INV HOR UP Molybdenum 14537 0.4
0.4 0.4 Zinc 12598 7 4 6 Iron 12598 8 71 13 Chromium 10660 1 1 1
Barium 6784 0.6 0.5 0.6 Tin 5815 1 1 1 Copper 2907 0.2 0.2 0.1
Manganese 2423 0.2 1 0.3 Lithium 2423 0.03 0.03 0.06 Gold 969 0.1
0.1 0.2 Antimony 872 0.6 0.6 0.6 Selenium 775 0.4 <QL <QL
Nickel 194 14 14 14 Arsenic 174 0.6 0.6 0.6 Aluminum 120 (5) <QL
(26) <QL (39) <QL Vanadium 97 <QL <QL <QL Silver 97
<QL <QL <QL Ruthenium 97 <QL 0.004 0.001 Rhodium 97
0.005 0.005 0.006 Platinum 97 <QL <QL <QL Palladium 97
<QL 0.02 0.02 Osmium 97 <QL <QL <QL Iridium 97 0.03
0.03 0.03 Thallium 78 <QL <QL <QL Cobalt 48 <QL <QL
<QL Lead 48 2 2 2 Mercury 29 0.7 0.7 0.7 Cadmium 19 <QL
<QL <QL XMHJ1702A 25.degree. C./60% RH Time point (months)
AEC 9 9 Element (ppb) INV UP Molybdenum 14537 1 0.5 Zinc 12598 17
17 Iron 12598 5 59 Chromium 10660 5 1 Barium 6784 1 0.4 Tin 5815 2
1 Copper 2907 1 0.4 Manganese 2423 2 1 Lithium 2423 8 0.1 Gold 969
7 1 Antimony 872 <QL 0.3 Selenium 775 <QL <QL Nickel 194
11 15 Arsenic 174 0.3 0.1 Aluminum 120 (9) <QL (5) <QL
Vanadium 97 3 <QL Silver 97 2 <QL Ruthenium 97 0.9 <QL
Rhodium 97 8 0.01 Platinum 97 2 <QL Palladium 97 1 0.1 Osmium 97
0.8 <QL Iridium 97 10 0.04 Thallium 78 7 <QL Cobalt 48 3 0.03
Lead 48 8 2 Mercury 29 1 0.6 Cadmium 19 0.5 <QL XMHJ1702A
XMHJ1702A
25.degree. C./60% RH 40.degree. C./75% RH AEC Time point (months)
Element (ppb) 0 1 2 3 6 0 1 2 3 6 Molybdenum 14537 2 N/A N/A 1.34
0.5 2 2 <0.5 1 0.4 Zinc 12598 42 N/A N/A 3.90 34.3 42 37 2 4
22.1 Iron 12598 284 N/A N/A 15.31 7 284 27 <QL 35 11.2 Chromium
10660 14 N/A N/A <QL 2.1 14 4 <0.5 <QL 2.1 Barium 6784 2
N/A N/A <QL <QL 2 2 <QL <QL <QL Tin 5815 3 N/A N/A
1.82 3.8 3 3 2 2 1 Copper 2907 4 N/A N/A <QL 123.1 4 2 <QL
<QL 0.1 Manganese 2423 5 N/A N/A <QL 0.1 5 1 <0.5 <QL
0.3 Lithium 2423 6 N/A N/A 3.92 0.2 6 6 <QL 4 0.2 Gold 969 7 N/A
N/A 3.45 0.1 7 4 5 4 0.1 Antimony 872 2 N/A N/A 1.08 <QL 2 2 1 1
<QL Selenium 775 4 N/A N/A <QL 0.4 4 2 <QL <QL <QL
Nickel 194 11 N/A N/A 8.93 8 11 9 4 8 8.1 Arsenic 174 2 N/A N/A
<QL 0.3 2 1 <QL <QL 0.3 Aluminum 120 <0.5 N/A N/A
<QL <QL <QL (3) <QL (8) <QL (7) <QL <QL
Vanadium 97 4 N/A N/A <QL <QL 4 3 <QL <QL <QL Silver
97 17 N/A N/A <QL <QL 17 17 17 <QL <QL Ruthenium 97 2
N/A N/A 0.76 <QL 2 2 <0.5 1 <QL Rhodium 97 8 N/A N/A 4.30
<QL 8 8 9 4 <QL Platinum 97 1 N/A N/A <QL 0.1 1 1 <0.5
<0.5 0.1 Palladium 97 1 N/A N/A <QL <QL 1 1 <QL <QL
<QL Osmium 97 1 N/A N/A <QL <QL 1 1 1 <QL <QL
Iridium 97 7 N/A N/A 5.98 <QL 7 7 9 6 <QL Thallium 78 5 N/A
N/A 3.59 <QL 5 5 6 4 <QL Cobalt 48 <0.5 N/A N/A <QL
<QL <0.5 <0.5 <QL <0.5 <QL Lead 48 6 N/A N/A 5.01
1.6 6 6 6 5 1.5 Mercury 29 2 N/A N/A 0.81 1 2 1 1 1 1.1 Cadmium 19
2 N/A N/A 1.37 <QL 2 2 1 1 <QL XMHJ1702B XMHJ1702B 25.degree.
C./60% RH 40.de